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1 Gross 8/27 I. Embrology A. Oocyte-forms in ovary(meiosis) [inside oocyte- DNA, cytoplasm, nutrients, all organelles] 1. Primary oocyte-Meiosis I Starts as primordial folliclesgoes through maturation processprimary oocyte released *becomes zygote after fertilizationmeiosis IIsecondary oocyte secondary oocyte surrounded by zona pellucida—impermeable to sperm/protection B. Fertilization—in fallopian tube 1. Sperm join with oocytezona pellucidaprevent polyspermy and implantation in oviduct. C. Zygote (fertilized oocyte)-goes through fallopian tube to uterus 1. after zygote is formed-undergo rapid series of cell division— cleavage(figure 2 handout) 2. Daughter cells are identical-no genetic recombination. Size of zygote stays same—divided cells shrink with each divisionincrease ratio of DNA chromosomes (nuclear) to cytoplasm(more DNA than cytoplasm) D. Morula-32 cell stage-reaches uterus at this time (about day 5) 1. upon reaching uterus—zona pellucida begins to dissolve—enzymes break down the biochemical molecules that form from the membrane. 2. Big solid ball of cells 3. then forms blastocyst(early;late)—around day 5. Blasomeres orient themselves into the blastocyst structure E. Blastocyst is the structure that implants itself into the uterus lining (endometrium) Hormones are released by female to help implantationprogesterone and enzymes from the zygote(eat some endometrial lining to help proliferate into uterus. F. Blastocyst starts to form cell layers Trophoblast--- cell layer developed around blastocyst (figure 3) -some cells from trophoblast invade uterus syncitiotrophoblast *blastocyst differentiates into inner cytotrophoblast and outer synsytiotrophoblast which invades uterine lining to anchor embryo. * synsytiotrophoblast also produces HcG (human chorionic gonadotropin) G. At end of first week – flattened disc of cell mass (embryoblast) – figure 4 – Embryonic hypoblast forms from it. H. Week two of development 1. Bilaminar embryonic disc is formed from embryoblast 2. Epilast then forms – forms amnionic membrane 3. Hypoblast – starts the development of the membrane that will enclose the yolk sac—exocoelomic membrane *extra embryonic space which develops between cytotrophoblast and hypoblast cells -mesoderm begins to form in this extra embryonic space. Figure 5—Day 14—well attached to uterus 2 8/30/1999 6. Placental and Fetal Membranes separate fetus from mother and allow exchanges embryo—first 8 weeks fetal—remainder until born baby—born 1. Fetal a. chorionic membrane—from trophoblast—becomes part of the placenta b. amnion—from epiblast c. yolk sac—from hypoblast(become part of the umbilical cord)[UC] d. allantois—from hypoblast (b/c part of UC also) erythrocytes form here 2. Placenta a. fetal—from chorionic sac b. maternal portion—from endometrium H. third week of development—cell layers formed 1. Formation of trilamminar embryo ectoderm—outside mesoderm—middle }refer to handout 8-30 endoderm—inside also formation of nervous system by the eighth week, all organ systems are formed I. Twins 1. monozygotic (identical) a. derived from single fertilized egg b. usually one placenta c. separation will occur at/before early blastocyst stage cells are omnipotent—can develop into anything 2. conjoined twins a. siamese twins b. split is incomplete;share organs 3. dizygotic a. fraternal twins b. two separate sperm;two separate eggs c. two placentas Introduction/Review I. Anatomical Position A. Body planes B. Anatomical directional terms C. Abbreviations D. Anatomical variation E. Skin Surface anatomy always first 3 1. Langer’s lines—patterns of parallel collagen fibers— cut parallel with lines— incisions will gape less and heal faster 2. Flexure lines—at joints—where skin is anchored to the deep fascia—holds skin in place. Usually at places with a lot of stress (hands; soles,etc) 3. tone—dark pigment made in response to damage p.13—parts of the skin 4. glands—sebaceous and sweat 5. Fascia 9/1/99 F. Superficial fascia—directly underlies skin (subq, adipose, cutaneous nerves, blood vesselsserving dermis, face and neck muscles are woven with superficial fascia (all facial expressions) G. Deep fascia—wrap individual organs. Run in fascial planes –fibers run in specific directions. Clinical significanceinfections will follow these planes. II. Bones A. Shape—genetically determined B. Decalcification=flexible Lose collagen=brittle C. Compact bone (solidified;shaft of femur); spongy bone (cancellous bone)—on ends of bone—slightly more flexibility D. Ossification—process of bone formation Apositional growth—increase length Intramembranous ossification—increase girth of bone E. Ca++,P reservoir; blood cell production make blood cells in red marrow—(adult—flat bones of cranium, ribs, sternum) F. Classified by shape (long bones, short bones) Long—femur Short—carpals Flat—cranial Irregular—wrist Sesamoid—patella (develop in tendons—found where tendons cross the ends of long bones—protect tendons from excessive wear & change angle of tendons G. Joints—Arthroses—grouped structurally 1. fibrous (sutures)—tibia; fibula—immovable 2. Cartilagenous—primary-synchondroses—ribs to sternum; secondarysymphysis (pubis) *slightly moveable 3. synovial—freely moveable (90% of joints) covered in synovial membrane (capsule)—secretes fluid to lubricate joint a. bones meet by way of articular cartilage (hyalin) 3 types of cartilage in general—hyalin; fibrous; elastin b. bursa—fluid filled pad—inflamed (bursitis) 4 c. Ligaments (bone to bone) d. menisci stability—due to shape of articular surface, arrangement of the ligaments, and the muscles themselves. H. bone terms Foramen—small hole through a bone Fossa—deep depression Condyle—small protuberance with articulation on surface Fissure—slit Tuberosity—big round knob—connects muscles Tubercle—small raised eminence Canal—large hole through bone Crest—ridge of bone Epicondyle—eminence superior to a condyle Facet—smooth flat area where a bone articulates Malleolus—rounded process Protuberance—projection of bone Trochanter—large blunt elevation Tuberosity—large rounded elevation III. skeletal muscles—40% of body mass—structural unit of a muscle is a muscle fiber. Motor unit—muscle fiber and its motor neuron A. origin—immovable attachment Insertion—movable attachment Innervation—nerve supply Action—main action (flex/ext; abd/add; etc) B. know all directional terms C. primary movers—eg. Biceps brachi—primary mover and brachialis is helper Three layers of muscle Superficial—very susceptible to damage Middle Deep—these help when superficial are damaged D. synergist—two muscles; same action E. antagonist—(biceps/triceps) Fixators—steady proximal parts of a limb, while movements occur distally F. names Named according to different things Origin/insertions (sternocleidomastoid) Shape (trapezius, deltoid, etc) Interosseus (between fingers) Position Actions G. w/in tendons—sesamoid bones (patella) Wormian bones (extra bones within sutures) H. neuromuscular junction—ACh released 1. contraction follows all or none law for each fiber strengthnumber of fibers recruited 5 2. whole muscle has graded response due to number of fibers contracted 3. special receptors to sense how many cells are needed—Golgi Tendon Organs and muscle spindles (only in skeletal muscles) IV. Smooth muscle—circular/longitudinal sheets A. innervated by autonomic nervous system B. GI tract—rhythmic contractions—peristalsis V. Cardiac muscle—autorhythmicity (beat without signal from the brain) A. Myocardium—middle Epicardium—out Endocardium—in VI. Nervous system A. CNSbrain and spinal cord B. PNSnerves that connect the CNS with peripheral structures 12 pair cranial nerves 31 pair spinal nerves -Peripheral nerve—bundle of nerve fibers held together by a connective tissue sheath. -Collection of nerve cell bodies outside the CNS is a ganglion. C. neuron structure (p. 38,9—know structure) 1. myelin sheaths 2. mixed nerves (sensory and motor) neuron—individual (innervate each muscle cell) nerve—big cluster—up through s.c. to brain 3. sensory 4. motor—very few that are only one—most are both sensory and motor D. neuroglia—help neurons by nourishment/phagocytize, etc E. spinal nerves—branches that innervate skin and muscles that are derived from surface embryology somite (regions of body) *particular s.n’s serve specific areas of the body 9/3/99 V. Circulatory System (chapter 1—chung) A. Pulmonary and systemic circuits B. Artery vs. vein (valves; etc) C. Anastomoses—arteryvein; with no capillary bed, therefore no precapillary sphincter. Can also be arteryartery D. Names Arteries named first Vein same name as accompanying artery Only the largest veins and those major veins that do not accompany arteries have special names. E. Portal System—2 capillary bed system—veincapveincap/or arteycap;etc. 1. venous portal system—hepatic portal system 2. arterial portal system—pituitary 6 F. Fetal circulation (p. 11—Chung) 1. oxygenation of blood occurs in the placenta 2. three shunts that bypass lungs and liver a. foramen ovale—connection b/t RA and LA which bypasses the lings b. ductus arteriosis—shunt from pulmonary trunk to aorta— bypass the lungs c.Ductus Venosus—shunt O2 blood from umbilical vein to the IVCbypass liver G. Layers of Blood vessels 1. Tunica adventitia outside—connective tissue; some mucle 2. Tunica muscularis—smooth muscle 3. Tunica intima—epithelial tissue/elastic fibers III. Lymphatic System A. Blind end capillaries Intertwined together with arteries and veins at all but one place—absent in the brain, spinal cord, eyeballs, bone marrow, splenic pulp, hyaline, cartilage, nails, and hair B. Vessels with valves C. Thoracic duct—drain lower body and left side D. Right lymphatic duct—drains upper right side E. Empty into subclavian vein F. Body immunity—lymph nodes filter out bacteria; etc G. active in spread of ca cells. If in lymphatic systemspread thoughout body H. not visible in dissections (except R and L duct) I. Lacteal—small intestineabsorbs fats and processed through lymph system before dumping into subclavian vein J. Peyer’s patchesileum—increased concentration of lymphatic tissue in certain areas K. Tonsils, spleen, thymus—also have high concentrations of lymphatic tissue Back and Spinal Cord [p. 233 Chung]; p. 432 clinical I. Surface Anaotmy Spine of scapula Acromion process Inferior angle of scapula is at spine of T7 Iliac crest at level of pine of L4 Vertebral prominence—C7 II. Back—vertebra p. 436 A. Primary curvature—thorax and sacral –concave anteriorly (newborn has these only) 7 B. Secondary curvature—lumbar and cervical (when baby can stand then the secondary curvature will have full development. Development may be somewhat when he/she can sit) C. Kyphosis—hunchback Lordodsis—sway back Scoliosis D. Foramen Vertebral foramen—spinal cord Intervertebral foramen—spinal nerves—31 pairs Transverse foramen—found in cervical vertebrafor vertebral arteries (1 on each side) E. Processes of vertebra 1. spinous process; transverse process F. Cervical vertebra (transverse foramina) 1. C1—Atlas –has no body or spinous process C3-C6—have bifid process 2. C2—Axis a. has dens/odontoid process 3. C7—long non-bifid spinous processvertebral prominance 9/8/99 G. Vertebrae Thoracic has articular facets for ribs. Flat facets. Lumbar do not have factes for ribs. Scalloped facets Facets have priority H. Spina Bifida—failure of the fusion of the vertebral arches (lamina/pedicle) I. joints of the vertebral column 1. intervertebral discs made of fibrocartilage (strongest) a. annulus fibrosus—fibro.cart. (outer circumference) b. nucleus pulposes (center)—jelly-like bag made up of collagen and H2O. 2. herniated disc—spine gets out of line (hit/crash)—pedicle gets stressednucleus pulposus inflames and protrudes out pinch spinal cordpain 3. Ligaments—one transverse process to another one body to another one spinous process to another a. longitudinal ligaments (anterior and posterior) join entire vertebra and all intervertebral discs p.455 b. deep to longitudinal ligaments ligamentum flavum—connects lamina of adjacent vertebra c. interspinous ligaments(also deep to longitudinal ligaments)— connects spinous process and adjacent vertebra d. Ligamentum nuchae—runs along spines of cervical vertebra, on both sides—up to external occipital protuberance 8 4. Atlanto-occipital joint—atlas to occipital condyles the yes movement 5. Atlanto-axial joint—atlas to axis (synovial joint)—cavity, fluid, etc. the no movement p. 490—x-rays J. Lumbar Triangle Bounded by iliac crest; latissimus dorsi; posterior free border of the external oblique K. Quadrangular space Up high on triceps insert Lateral—surgical neck of humerus Medial—long head of triceps Superior—teres minor Inferior—teres major NERVE—axillary n ARTERY—posterior humoral circumflex (goes around humerus) Break humerus—watch this artery L. Triangular Space Superior—teres minor Inferior—teres major Lateral—long head triceps ARTERY—circumflex scapular a. (wraps around scapula) M. Triangular Interval Superior—teres major Medial—long head of triceps Lateral—medial head of triceps NERVE—radial n. ARTERY—deep brachial *Quad and tri space—almost horizontal to eachother *interval is inferior p. 32—chung N. Spinal Cord p. 479;480 1. 3 meninges—cover brain and spinal cord a. dura mater—tough—extend to S2 contains epidural space external to dura—filled with fat and connective tissue and the vertebral venous plexus contains subdural space internal to dura; external to arachnoid—filled with interstitial fluid b. arachnoid mater—contains arachnoid granulations—important for the return of fluid and blood to the circulatory system—extends to S2 has fine extensions into the subarachnoid space—CSF is in this space 9 c. pia mater—C.T. directly adhered to CNS—looks like surran wrap contains blood vessels denticulate ligaments—spike-like projections holding cord in center—stabilize spinal cord. Also CSF is around it for shock absorber 2. Cauda Equina—formed at L2-S5 aside—bone grows faster than nerve—that is why spinal column is longer than vertebra—differential growth rates between nerves and bone 9/9/99 3. Spinal tap—p. 483 lay down and bend—pull apart vertebra and allow for insertion of needle—done b/t L3 and L4—to extract CSF from subarachnoid space 4. Epidural—p. 455 needle through sacral hiatus—inject anesthesia (p. 484) in that spot (epidural space) 5. spinal nerves p. 478—31 pairs C8, T12, L5, S5, C1 Divided up into dorsal and ventral rami **Info comes in dorsal, afferent sensory, goes out ventral, efferent motor neuron—see old A&P book --Ventral rami— contain somatic efferent neurons (cell body in dorsal root ganglion)—very long axons somatic visceral and motor neurons (also called intercostal nerves in thorax) --Dorsal rami— branch off of spinal nerveinnervate skin and deep muscles of the back—they innervate a specific area of skin known as a dermatome --C1—has no dermatome—Picture in Chung 6. Autoniomic nervous system— a. parasympathetic branches long preganglionic neuron very short post ganglionic neuron ganglion is at or in the organ of innervation aside—ganglion—mass of cell bodies outside the CNS nuclei—mass of cell bodies inside the CNS b. sympathetic short preganglionic neuron—synapses quick with post.gang fiber sympathetic chain ganglion/paravertebral (string of pearls)—along both sides of vertebral column 7. Blood supply to the spinal column—p. 487 CNS has no lymph vessels—can’t replace lost fluid 10 Two pairs of spinal arteries Suply posterior 1/3 of column Anterior spinal artery supplies anterior 2/3 of spinal column— originates from vertebral artery (anterior fissure of spinal cord is bigger, therefore b.v. branches more and can supply more blood) Aside—arterial end has higher osmotic and hydrostatic pressure than venous side, therefore, net loss of fluid across capillary bed Venous drainage—internal and external venous plexi p. 466 More extensive than arterial supplyneed to get all excess fluid out so no swelling. Thorax I. A. Muscles 1. Pectoralis Major o: clavicle, sternum, ribs 3-6 I: greater tubercle of humerus I: medial and lateral pectoral n. A: flexes, adducts, rotates arm medially 2. Pectoralis minor o: ribs 3-5 I: coracoid process of scapula I: medial pectoral n. A: depress scapula, elevate ribs 3. Serratus anterior o: upper 8 ribs I: vertebral border and inferior angle of scapula I: long thoracic n. A: rotate scapula upward and laterally, abduct the scapula 4. External intercostals o: inferior border of rib above I: superior border of rib below I: laterocostal n. A: elevates ribs during inspiration Look written notes 5. Internal intercostals o: superior border of rib below I: inferior border of rib above I: intercostal n’s A: pulls ribs together during expiration 11 6. Diaphragm—autonomic and voluntary o: xiphoid process and costal cartilage of last 6 ribs, lumbar vertebra I: central tendon I: phrenic n. A: floor of thoracic cavity and assists in filling lungs 9/10/99 II. Thoracic Wall A. jugular notch B. sternal angle/angle of louis—at rib 2 C. nipple—4th intercostal space D. breasts—(mammary is a modified sweat gland) 1. composed of fat, fibrous tissue (for support), and ducts p. 73-4 2. aereolar glands (sebaceous)—for lubrication 3. divided into lobes that drain fluid into lactiferous ducts into nipple suspensory ligaments b/t lobes and superficial aspect of skin— support tissue 4. lies in superficial fascia—mammary gland covering pectoralis major 5. lymphatic drainage (p.76) decides path of tumor spread 70% of lymph from mammary drains to axillary nodes 6. Blood supply—p. 75 internal thoracic artery (major branch of subclavian artery) some supply from axillary a. ; some supply from intercostal a. aside—skin—refers to epidermis and dermis; integumentary refers to epidermis, dermis, and subq (superficial fascia) 7. Nerve supply—intercostal n.’s from T4-T6 8. oxytocin—milk ejection, contractions of uterus—made in hypothalamus—stored in posterior pituitary (secreted during and after birth) 9. prolactin—milk production—made in anterior pituitary—lactation inhibits ovulation (secreted while pregnant) 10. cancer—60% of all tumors arise in superior lateral quadrant— fibrous cysts in other quadrants—but won’t be cancer (usually) E. intercostal space 1. each costal groove has VAN (between innermost and onternal intercostals, in costal groove—vein surerior; artery middle; nerve inferior. 2. anterior intercostal a.—derived from internal thoracic a. 3. posterior intercostal a.’s—derived from aorta (except upper two are derived from subclavian) F. BV’s of chest wall (p.81-2; Netter p. 179, 176) 1. internal thoracic artery and vein branch from first part of subclavian, run lateral to sternum. a. divide at 6th intercostal space into superior epigastric a. (to abdomen) and musculophrenic a. to diaphragm and lower intercostal spaces 12 Draw arteries 9/13/99 b. pericardicophrenic a.—branches from internal thoracic—follows phrenic n. to pleura, goes through pericardium and diaphragm 2. Anterior intercostal veins—drain into internal thoracic veins (internal thoracic veins empty into subclavian v.’s.) 3. Posterior intercostal veins— -veins from first three intercostal spaces drain directly into brachiocephalic veins (on both sides) -the rest of them drain into the azygos venous system 3 veins make up the azygos venous system—p. 131 chung a. (Right side)—azygos vein—formed from the union of the R ascending lumbar vein and the R subcostal vein—azygos drains R intercostal vein and empties into SVC. Azygos pierces through diaphragm and enters thorax at aortic hiatus (same place that aorta does) b. (Left side)—Hemiazygos vein—formed from L ascending lumbar and L subcostal vein. Hemiazygos drains left 4 inferiormost intercostal veins. c. Accessory hemiazygos—begins at 4th intercostal space; drains th th 4 – 8 intercostal veins. **first intercostal vein drains directly into brachiocephalic on both sides. --hemiazygos and accessory hemiazygos drain into azygos 13 G. Diaphragm—anchored by ligaments 1. aortic hiatus—thru diaphragm at level of T12 2. esophageal hiatus—level of T10 3. IVC—level of T8 III. Mediastinum—chung p. 115; moore p. 114 Region between parietal pleural membranes A. Superior mediastinum Area beneath 1st rib and along the line posterior to the sternal angle B. anterior mediastinum Found immediately behind the sternum C. Middle mediastinum—largest portion— region located posterior to anterior mediastinum between sternal angle and diaphragm, anterior to vertebra. D. Posterior region of mediastinum—posterior to middle mediastinum inferior to superior mediastinum and just anterior to vertebra—floor is the diaphragm Diaphragm is floor of ant, mid, and post regions E. Middle mediastinum contents—moore p. 120 1. pericardial sac—on surface—phrenic n. and percardiacophrenic vessels lie in surface a. fibrous pericardium (outer)—tough tissue that blends with tissue surrounding roots of the great vessels and also central tendon of diaphragm (fans out at diaphragm) b. serous pericardium (2nd layer—more interior) -parietal layer—lines inner surface of fibrous pericardium -visceral layer—outer layer of heart wall (fused with the epicardium) c. Pericardial cavity—a potential space b/t visceral and parietal layers. (has serous fluid)—if this space b/c filled with blood or excess fluid—inhibits heart function by placing excess pressure on the heart; therefore need pericardial aspiration. d. sinuses—moore p. 118-9 -transverse sinus—lies behind aorta and pulmonary trunk, but anterior to the L atrium and SVC—formed by serous pericardium -oblique sinus—lies behind the heart and is bound by reflexions of serous pericardium around R and L pulmonary veins and IVC e. Clinical comments -cardiac tamponade—acute compression of heart due to rapid fluid accumulation in pericardial sac—bp down; hr up -constrictive pericarditis—inflammation of the parietal layer of serous membrane -rubs against fibrous pericardium—painful -sounds like rustling of silk when heard by auscultation f. innervation—pain carried by somatic (body wall) afferent neurons. Afferent sensory from phrenic and vagus. (somatic—conscious; sensory— afferent; autonomic—unconscious; motor—efferent) 14 --epicardium innervated by cardiac plexus (formed from the vagus nerves)—insensitive to pain --pericardial pain—felt posterior to sternum (usually due to inflammation) g. blood supply—pericardicophrenic a.(—from internal thoracic); also branches of bronchial and esophageal arteries 9/15/99 2. Heart a. muscle layers—epicardium; myocardium; endocardium (continuous with interior of great vessels. P. 123-4 b. Cardiac characteristics—p. 123-4 Two regions (base and apex); four surfaces (diaphragmatic, sternocostal, right, left) --Base—posterior surface of heart—composed of mostly LA, and small portion of RA --Apex—located anteriorly, inferior, and just to the left of the base; usually consisting of LV --Diaphragmatic surface—inferior surface of the heart; portion that extends from the base to the apex (consists of LV and portion of RV) --sternocostal surface—anterior surface—consisting of RV, R. auricle, and small portion of LV --right surface—faces the R. lung and composed mostly of RA --Left surface—faces the L. lung and composed mostly of LV c. blood flow through the heart—p. 121 SVC/IVCRAtricuspidRV pulmonary semilunar valve pulmonary trunk L and R Pulmonary arterieslungsPulmonary veins (4)LAmitral/bicuspidLVaortic semilunar valveascending aortasystemic 3. Heart chambers—moore p. 126, netter p. 208-210 a. RA –walls relatively smooth except for pectinate muscles --fossa ovalis—represents remnant of foramen ovale (bypassed blood from RALA—bypassed pulmonary circulation) --Auricle—muscular pouch of RA. Covers first part of coronary artery (off of aorta) --Crista Terminalis—(seen externally)—is the junction b/t smooth and rough areas of the internal wall—seen as sulcus terminalis—at the cephalic end is the SA node --smoothe walled portion—recieves SVC, IVC, coronary sinus, and the anterior cardia veins --ridges—pectinate muscles --venae cordis—the tiny cardiac veins from around the heart --Ch.p. 127—tricuspid valve—lies behind the R side of the sternum at the level of the 4th intercostal spacehas 3 cusps—held in place by 15 connective tissue—chordae tendinae (very tough)—anchors to pappilary muscles— extend from wall of RV --Auscultation over lower R tip of sternum b. RV p. 128 --makes up most of the anterior surface of the heart --rough inner wall caused by trabeculae carnae (network flesh)— muscular ridges --papillary muscles to anchor tricuspid --chordae tendinae—located in RV --conus arteriosis—of the pulmonary trunk—remnant of ductus arteriosis (bypassed blood from pulm trunk to aorta) --moderator band—extends from interventricular septumbase of the anterior papillary muscle (it carries the R limb of the AV Bundle) --p. 127—pulmonary valve—located at the medial end of L 3rd costal cartilage --auscultation over L 2nd intercostal space c. LA—p. 129—in body cavity—more posterior than RA—much smaller than RA; has smooth wall --Auricle—contains pectinate muscles --mitral/bicuspid valve—located behind L side of sternum opposite 4th costal cartilage --auscultation over L 5th intercostal space at mid-clavicular line --openings of pulmonary veins (4) d. LV—moore-p. 130—most muscle mass—3x mass of RV --ridges in walls—trabeculae carnae --aortic vestibule—leads to aorta --aortic semilunar valveslocated behind L half of sternum, opposite 3rd intercostal space --auscultation over R 2nd intercostal space --above valve—aortic sinuscontains openings for the coronary arteries—moore p. 130 (bottom) --coronary circulation fills during diastole 9/17/99 4. Aorta— a. divisions 1. ascending aorta—coronary arteries come off of 2. aortic arch—R braciocephalic trunk a. L common carotid L subclavian 3. descending aorta descending thoracic aorta begins about T4 and descends on L side of vertebral column 16 4. Coarctation—chung p. 136 --constriction of part of the aorta—abnormal --if it occurs distal to the L subclavian—circulation will be adequate --if it occurs proximal to L subclavian—adequate collateral circulation does not develop --results in tortuous and enlarged blood vessels, especially the internal thoracic, intercostal, epigastric, and scapular arteries --elevated blood pressure in radial a. and decreased bp in femoral a. 5. abdominal aorta 5. Innervation— a. parasympathetic—vagus supply all of the thoracic and abdominal viscera except for descending and sigmoid colon and pelvic viscera—this innervation comes from pelvic splanchnic nerve (sympathetic)—branches off of thorax --L vagus nerve gives off a L recurrent laryngeal nerve (between esophagus and trachea) b. sympathetic—runs along vertebral column through sympathetic chain gangla—gives off greater and lesser splanchnic nerves to abdomen --there is no parasympathetic innervation to sweat glands --the sympathetic post ganglionic fiber is bigger than preganglionic fiber. Sympathetic post to periphery goes gray ramus communicans.—pre symp and para go white ramus communicans c. cardiac plexus—superficial and deep—sends branches to SA node and AV node—contains both parasympathetic and sympathetic fibers d. phrenic nerve— formed from the ventral rami (C3-C5) and carries motor fibers to diaphragm and carries sensory info from mediastinum; R is found running over R anterior scalene; L is found between carotid and subclavian arteries (more medial than R) --Vagus gets to thorax and branches into fishnet (can’t see it anymore)—Phrenic doesn’t branch at that point, therefore, can see phrenic 6. Artrial blood supply to heart (coronary arteries—2) a. right coronary artery—supplies RA and RV --arises from R aortic sinus: branches—sinoatrial branchSA node marginal branchanterior R ventricular wall posterior interventricular branchb/t ventricles in interventricular sulcucto posterior wall of RV b. left coronary artery—shorter than right --supply more of myocardium than right (bulk wise) Branches— LAD—left anterior descendingL anterior portion of ventricle 17 L circumflexgo around the L margin of heart and feed posterior LA and posterior LV Marginal branchto lateral wall of LV AV nodal branchto AV node p. 124 chung 7. Venous drainage a. great cardiac vein—follows LAD a. b. middle cardiac vein—follows posterior interventricular branch of R coronary artery c. small cardiac vein—follows R marginal branch d. posterior vein of LV—found with the posterior ventricular branches of L circumflex artery e. all drain into coronary sinus (largest vein in heart system)—lies in coronary sulcus, opens into the RA, near the IVC opening and drains great, middle, small, and posterior veins—refer to 134—moore 9/20/99 IX. Conducting System A. Sinoatrial node—pacemaker—upper end of crista terminalis of RAinitiates heart beat. Sympathetic speeds HR; parasymp slows HR. Sinoatrial a. feeds it—derived from right coronary artery B. Atrioventricular Node—beneath endocardium in atrial septum—AV nodal a. feeds it (derived from posterior branch of interventricular a. of L coronary a. C. Bundle of His—runs along interventricular septum; at apex it branches to both ventricles (L and R BB’s) D. Purkinje cells—terminal conducting fibers for the ventricular walls (within the myocardium) X. Cardiac Cycle A. SA node initiates pulse—heart is relaxed prior to firing. SA firesAV valves open, ventricles fill with blood (hi to lo pressure) Atrial systoleP wave/atrial depolarization B. Impulse passed to AV node to purkinje system—AV valves close (lub sound)—lowest arterial pressure at this point C. Ventricles contract—semilunar valves openblood ejected (70-90mL)— corresponds to QRS complex/ventricular depolarization. After ejection of the blood— dubb sound (caused by semilunar valve closure) D. Ventricles relax—blood flows from vena cava (to RA); and pulmonary veins (to LA)—ventricles repolarizeT wave. E. Cycle repeats XI. Thymus—two lobes found in superior mediastinum; blood supply via branches of internal thoracic a. (from subclavian) and inferior thyroid a (from thyrocervical trunk) 18 RESPIRATORY SYSTEM I. Respiratory components: the respiratory system is a series of tubes and cavities that conduct air into and out of the lungs for the purpose of gas exchange. Major structures constituting this system: Nasal cavity/mouthpharynx (warm, moisturize, filter)larynx(thyroid cart; cricoid cart; epiglottistrachea branch into R and L primary bronchi—secondary— tertiary—quaternarybronchioles (one layer of smooth muscle and no cartilage)alveoli II. Trachea (windpipe) is approximately 2-2.5 cm (1 inch) in diameter and 4 inches in length. Extends from larynx (C6) to the level of the sternal angle (rib 2/T4), where the trachea splits into primary bronchi—trachea consists of 20 C shaped rings of hyalin cartilagerings are linked posteriorly by trachealis muscle (smooth muscle) Tracheal carina—the downward and backward projection of the last cartilage ring III. Primary Bronchi (main)— A. Begins at the birfication of the trachea—gives rise to more branches—on R— superior, middle, and inferior secondary bronchi; on L—only superior and inferior 1. Right main bronchi—shorter and wider and more vertical than leftmore clinical problems—foreign objects progress all the way to lung 2. Right primary bronchus—runs over top of pulmonary vein but under the arch of the azygos vein 3. Right bronchus—divide into superior, middle, and inferior secondary bronchi 4. Left bronchus—cross anterior to esophagus and divide into superior and inferior secondary (lobar) bronchi B. Secondary bronchi gives rise to tertiary bronchi (segmental bronchi)— functional unit of lung. If collapse—localize at from the rest of the lung and the healthy part of the lung will work fine. IV. Lungs A. Pleura—thin serous membrane that lines inner surface of the mediastinum --Layers of pleura 1. Parietal pleura—moore p. 95—lines the wall of thorax and has costal, diaphragmatic, mediastinal and cervical portions—cervical also called cupola 2. Visceral pleura—invests the lung tissue and dips into the fissures separating the lobes of the lung 3. Cupola of pleura—moore p. 97—dome of parietal pleura that projects into the neck at the level of the first rib. 4. Pulmonary ligament—double layer of mediastinal pleura—extends from hilus of lung to its base (membrane folds over on itself and forms ligament) B. Cavities—p. 96—potential spaces between the parietal and visceral pleura that also contains a film of fluid 19 1. costodiaphragmatic recess—infection here—infra-lateral on each side of chest where edge of diaphragm meets the chest wall 2. costomediastinal recess—chung p. 118—anterior to heart on left side 3. endothoracic fascia—behind pleura (lines same areas as pleura)— covers transverse thoracis, and innermost intercostals 9/22/99 C. Lung Characteristics 1. right lung larger than left lung 2. right has three lobes. Left has two lobes and cardiac notch—also has lingula—coming off of superior lobe/wraps around inferior portion of heart 3. right has horizontal and oblique fissure. Left has oblique fissure 4. right receives single bronchial artery. Left gets two bronchial arteries 5. left lung has the lingula 6. Bronchopulmonary segments: are the anatomical, surgical and functional units of the lungs. These segments consist of tertiary bronchus, the portion of the lung it serves, a segmental artery, and its corresponding vein. C.T. will separate these segments. Can remove individual segments and others will work fine. Right lung Left lung Lobe Superior Middle Inferior Segment Apical; ant; post Medial, lateral Sup, ant, post, med, lat Upper Lower Lingula Apical-post, ant Sup, ant, post, med, lat Sup, inf D. positions and surfaces 1. apex—superior end; cupola—rises above clavicle into root of neck 2. base—rest on surface of diaphragm 3. hilus/root of lung—see drawing in notes—area where vessels, etc, enter and exit the lung—find primary bronchus, pulmonary a. and v. and lymphatic vessels. Also have nerves—vagal parasympathetic fibers; sympathetic fibers from chain ganglia (can’t see, too small) E. Pulmonary (intersegmental drainage)/bronchial veins 1. superior right vein—drains superior and middle lobes (middle and superior join to for superior right vein) 2. superior left vein—drains superior left lobe 3. inferior right and left veins—drains their respective lobes 4. bronchial veins—empty into azygos vein on right and into hemiazygos on left. 20 F. pulmonary arteries—bp in pulmonary trunk always lower than aorta. Lung tissue could not handle higher pressure 1. left is shorter and narrower in diameter than right—connected to aorta by ligamentum arteriosis 2. right runs under aortic arch behind svc and just anterior to the right bronchus G. bronchial arteries—could have 2-5. Branch from thoracic aorta—one to the right and two to the left (but can vary)they supply O2 to the non respiratory tissues of the lung (cartilage, smooth muscle, etc) Right pulmonary artery branches quick—two entry points into lung Left pulmonary artery branches inside lung—one entry point into lung H. respiration 1. inhale—diaphragm contracts, causes ribs to elevateair pulled in (hi to lo)—other muscles involved—external intercostals, interchondral part of internal intercostals, innermost intercostals, scm, levetor scapula, serratus anterior, scalenes, pec major and minor, erector spinae, serratus post superior. (hypertrophy of lev scap— breathing problems) 2. Exhale—passive due to relaxation of muscles abdominal wall, internal, intercostals, serratus post inferior 3. pneumothorax—air/gas in pleurl cavity—alters pressure—lungs can’t expand as well EXAM I TO HERE 21 9/24/99—for exam II The Abdominal Cavity --separated from thoracic cavity by diaphragm --well protected by muscoluskeletal walls A. Abdominal Wall 1. abdominal examination is made through the thin, relaxed, anterior abdominal wall a. umbilicus—found between borders L3 and L4 (intervertebral discs) 2. subdivisions—9 regions --two horizontal planes (transpyloric or subcostal plane, and transtubercular (intertubercular )plane) a. transpyloric (subcostal) plane—passes midway through the umbilicus and xiphoid process of the sternum b. transtubercular (intertubercular) plane—passes through the tubercles of iliac crests c. Midclavicular lines (R and L lateral lines)—(2)—vertical—passes through the middle of the clavicle d. epigastrum—center—above subcostal plane e. hypochondrium—center—below transtubercular plane f. umbilical region—bordered superiorly by subcostal plane, inferiorly by transtubercular plane, laterally by midclavicullar lines g. lumbar region—lateral to umbilical region h. hypogastrium—inferior to umbilical (center) i. inguinal region (iliac)—lateral to both sides of hypogastrium Right hypochondriac Epigastric Left hypochondriac Right lumbar umbilical Left lumbar Right inguinal hypogastric Left inguinal 22 Four quadrants—sectioned using medial plane and transumbilical plane—know organs in quadrants RUQ LUQ Liver: right lobe Gallbladder Stomach: pylorus Duodenum: parts 1-3 Pancreas: head Right suprarenal gland Right kidney Right colic (hepatic) flexure Ascending colon: superior part Transverse colon: right half RLQ Liver: left lobe Spleen Stomach Jejunum and prox. ileum Pancreas: body and tail Left kidney Left suprarenal gland Left colic (splenic) flexure Transverse colon: left half Descending colon: sup. part LLQ Cecum Vermiform appendix Most of ileum Ascending colon: inferior part Right ovary Right uterine tube Right ureter: abdominal part Right spermatic cord: abdominal part Uterus (if enlarged) Urinary bladder (if very full) Sigmoid colon Descending colon: inf. part Left ovary Left uterine tube Left ureter: abdominal part Left spermatic cord: ab part Uterus: if enlarged Urinary bladder (if very full) 3. Superficial structures --intercostal nerves (thoracoabdominal nerves)—are from the ventral rami of thoracic spinal nerves --thoracoepigastric, intercostal, and superficial epigastric veins --forms a potential pathway between the femoral and axillary veins --indirect pathway between SVC and IVC becomes enlarged if IVC blocked --superficial fascia (fat)-adipose tissue—(Camper’s) --deep fascia (membraneous)—fascial sheaths of abdominal muscles (Scarpa’s) p. 179 skinsuperficial fascia (fatty)membraneous (deep) layer of superficial fascia (scarpa’s)deep fasciaexternal obliquedeep fasciainternal obliquedeep fasciatransverse abdominal muscletransversalis fasciaendoabdominal (extraperitoneal) fatparietal peritoneum 23 4. Muscles of anterior wall a. external abdominal oblique (superficial) o: lower 8 ribs fibers fan out downward and medially (hands in pockets like external intercostals) b. internal abdominal oblique (middle) o: thoracolumbar fascia, anterior 2/3 of iliac crest, lateral 2/3 of inguinal ligament --fibers run upward and medial c. transversus abdominus (deep) o: cartilage of the lower 2 ribs, thoracolumbar fascia, iliac crest, lateral inguinal ligament d. for external, internal, and transverse abdominus muscles I: linea alba I: intercostal nerves (rami of T7-T11, branches of subcostal nerve(also called T12), and L1. A: compress abdomen, depress ribs e. rectus abdominus o: pubic crest I: cartilage of ribs 5-7, xiphoid process I: thoracoabdominal nerve (also called intercostal nerves) A: compress abdomen, flex lumbar spine f. rectus sheath p. 185--moore --encloses the rectus abdominus muscle --formed by the tendons of the external abdominal oblique, internal abdominal oblique, transverse abdominal muscles --tendon of external abdominal oblique lies anterior to rectus abdominus over its whole extent --below costal margin internal abdominal oblique contributes to anterior and posterior layers, transverse abdominus contributes to posterior layer --midway between the umbilicus and symphisis pubis all tendons pass anterior to the rectus femoris g. arcuate line—where the posterior layer of the rectus sheath terminates (arteries and veins come up from iliac and pierce the internal portion of abdominal wall and go superficial—if sheath was there they couldn’t get through) p. 185 h. transversalis fascia—protection—lies beneath the muscles of the anterior abdominal wall, separating muscles from extraperitoneal fat and parietal peritoneum(soft—provide fluid) 24 5. Histology (in to out) -hollow tube having four layers—lumen in center (bolus/chyme) a. mucosa—simple columnar epithelium i. lamina propria—connective tissue, lymph nodes to protect against disease (lacteals) ii. muscularis mucosa—thin layer of smooth muscle iii. absorption and secretion iv. goblet cells—secrete mucus (mucous refers to the membrane) b. submucosa—vascular layer, connective tissue, nerve plexus -autonomic innervation (para—increases, symp—slows) c. muscularis—segmental contractions and peristalsis which pulverizes and churns food --smooth muscle --inner circular layer --outer longitudinal layer}contraction in two different directions—increase efficiency d. serosa—(visceral peritoneum)—loose connective tissue, simple squamous epithelium 6. inguinal region (many clinical problems) p. 195—moore a. inguinal ligament (ligament is usually bone to bone—here it refers to the thickening of the external oblique muscle) --it is a thickening (folding over of) the lower border of the aponeuroses of external oblique muscle -- inguinal ligament runs from anterior superior iliac spine down to pubic tubercle 9/27/99 b. Superficial inguinal ring (begins inguinal canal) p. 195 moore--triangular gap in the aponeurosis of the external oblique muscle (superficial/lateral to pubic tubercle) contents— spermatic cord in males round ligament in females (ring is much reduced) ilioinguinal nerve to scrotum c. deep inguinal ring—lies in transversalis fascia just above inguinal ligament d. inguinal canal begins at deep inguinal ring and ends at superficial inguinal ring characteristics of inguinal canal— -not large—is a compressed slit—contents pushed very tight together -anterior wall—made up of aponeurosis of the external oblique and the internal oblique -posterior wall—formed by aponeurosis of transverse abdominus and transversalis fascia -roof of canal—formed by the arch of the internal oblique and the transverse abdominus 25 -floor—inguinal ligament and lacunar ligament (connects inguinal ligament to pectineal ligament e. conjoint tendon—Chung p. 225 formed by aponeurosis of the internal oblique and transverse abdominus and inserts on the pubic tubercle *bones respond to stress and strain by forming more bone (bigger bony prominances) f. spermatic cord—passes through the inguinal canal contents of spermatic cord— 1. ductus deferens (vas) 2. testicular artery (gonadal a.) 3. cremaster muscle and a. 4. pampiniform plexus venous system—valves stop return of blood during sex -pampiniform v. on R—connect directly to IVC; on L—connects to renal vein 5. autonomic nerves sheaths (surround structures of spermatic cord) -internal spermatic fascia—originates from transversalis fascia -cremasteric fascia—derived from internal oblique -external spermatic fascia—from the external oblique *fibers of abdominal wall that go all the way through the inguinal canal 7. Hernias—passage of some of the abdominal contents through a break in the abdominal wall a. inguinal hernia (indirect)—contents do not pass through the ab wall directly, passes through inguinal canal into scrotum (stuff just follows I.C.—doesn’t break tissue) --lies lateral to the inferior epigastric vessels b. acquired (direct)—contents move through the posterior wall of the I.C., lies medial to inferior epigastric vessels—p. 207 8. inner abdominal wall folds (peritoneal folds)—p. 192 a. lateral umbilical fold—extends from deep inguinal ring to the arcuate line—contains inferior epigastric vessels (branch from external iliac) b. medial umbilical folds—extend from lateral side of bladder to umbilicus—contains remnant of umbilical a. (which was a branch of the internal iliac artery) c. median umbilical fold—(1)—from urinary bladder apex to umbilicus, contains remnants of urachus –link of the embryo b/t bladder and extra embryonic allantois. d. medial inguinal fossa—depression in the interior abdominal wall b/t medial and lateral folds—where most acquired hernias occur e. falciform ligament—(peritoneal fold)—links liver to diaphragm and anterior abdominal wall—contains ligamentum teres (remnant of fetal life—umbilical vein)—extended from the umbilicus to the liver prenatally 26 10/1/99 B. Abdominopelvic Cavity (lies between the thoracic diaphragm and superior pelvic aperture/pelvic inlet. Diaphragm is the roof; has no floor b/c it is continuous with the pelvic cavity) 1. Lined by peritoneum, a bilayered membrane of simple squamous epithelium, forms mesentery a. parietal layer -lines abdominal and pelvic wall, plus the inferior surface of the diaphragm -innervated by somatic intercostal nerves, highly sensitive to pain b. visceral layer -envelopes or lines the surface of an abdominal or pelvic organ, autonomic innervation c. peritonitis -inflammation of the peritoneum -caused by trauma, bacterial infection (ascites), visceral organ rupture, post-op complications -painful and serious -treated by antibiotics and intubation (drainage) d. potential space between visceral and parietal peritoneum—peritoneal cavity -lesser sac—area behind liver, lesser omentum and stomach, closed sac -greater sac—remainder of intraabdominal cavity -epiploic foramen—connection b/t sacs 2. Development a. Epithelium and its derivatives arise from the endoderm b. muscles are derived from the mesoderm c. divided into three components -pharyngeal gut—gives rise to the pharynx and related glands -foregut—gives rise to esophagus, trachea, lung buds, stomach, proximal duodenum, liver, pancreas, and biliary apparatus -midgut—gives rise to distal duodenum, ileum, jejunum, ascending colon, and proximal 2/3 of transverse colon -hindgut—gives rise to the distal 1/3 of the transverse colon, descending colon, and upper part of the anal canal (the distal part of the anal canal arises from the ectoderm) d. During the early stages of development, the abdominal part of the digestive tract is suspended in the peritoneal cavity by a dorsal and ventral mesentery. Later in development, the ventral mesentery may disappear and the intestine (jejunum, and ileum) hangs freely from the dorsal mesentery. The intestine and the dorsal mesentery fall back against the abdominal wall. The intestine is then only partially covered by peritoneum and is said to be retroperitoneal. 27 3. Mesentery a. double sheet of peritoneum extending between two organs or an organ and an abdominopelvic wall region b. transmit arteries, veins, and nerves supplying intraperitoneal organs 4. Intraperitoneal a. organs that are almost completely surrounded by peritoneum b. stomach, ileum, jejunum, transverse colon, spleen 5. Retroperitoneal a. organs which are sandwiched between the posterior abdominal wall and the peritoneal lining b. organs partially covered by peritoneum c. abdominal aorta, IVC, kidneys, adrenal glands, ureters, duodenum, ascending and descending colon, rectum, and pancreas 6. Supracolic space—area from transverse colon to inferior surface of diaphragm, stomach, duodenum 7. Infracolic space—area from greater omentum attachment down **6 and 7 connect at paracolic gutter C. Alimentary Tract (digestive tract) -approximately 30 feet in length -innervated by autonomic nervous system -parasympathetic—vagus (upper GI), sacral (from lower portion of large intestine down)—increases peristalsis and secretion -sympathetic—sympathetic chain, decreases peristalsis and secretion, stimulates sphincter contraction 1. Oral cavity—mouth a. lips -retains food and saliva within the oral cavity -speech b. palate -roof of the oral cavity -consists of bony hard palate anteriorly and soft palate posteriorly from which uvula is suspended -soft palate and uvula drawn upward during swallowing, preventing food and fluid from entering nasal cavity (cleft palate—doesn’t work) c. teeth -mechanical break up of food d. tongue -taste—taste buds on papillae—small elevations -sweet sour salty bitter -speech -preparation and swallowing (movement) of food e. salivary glands parotid (ear), submandibular (mandible, part under masseter), sublingual (deep) 28 -saliva -starch-digesting enzymes (alpha amylase) mucus—lubrication for easy swallowing 2. Pharynx 3. Esophagus a. collapsible muscular tube -connects the laryngopharynx to stomach b. esophageal hiatus -left to midline -congenital diaphragmatic hernia: -incomplete formation of the diaphragm allowing abdominal organs to ascend into the thoracic cavity -hiatal hernia -portions of the stomach herniate through the esophageal hiatus -reflux of gastric contents into lower end of esophagus -may have difficulty swallowing and/or fullness after meals c. Histology -mucosa—stratified squamous epithelium d. abdominal blood supply from left epigastric a. v., innervation—vagus, splanchnic branches of sympathetic chain 4. Stomach a. in the left superior portion of the abdomen, inferior to the diaphragm -position and shape is not fixed, varies with position of the body, volume of contents, phases of repiration b. functions -stores food -initiates protein digestion -moves food into the small intestine as a pasty material called chyme c. 4 regions -cardia—narrow upper region below esophagus -fundus—dome-shaped portion in contact with diaphragm -body—large central region -pyloris (Gr. Gatekeeper)—funnel shaped terminal portion -pyloric sphincter -recognized by a thickening in the intestinal wall -regulates movement of chyme into duodenum of small intestine -prohibits backflow of chyme d. 2 surfaces covered by peritoneum -lesser curvature -medial concave border -lesser omentum (4 layers -extends b/t lesser curvature and liver (pora hepatis) and contains hepatic artery, bile duct, and portal vein (derived from ventral mesentery) 29 -greater curvature—lateral convexed border -greater omentum—2 layer -forms an apron-like structure over most of the small intestine -stores fat, cushions visceral organs and contains lymph nodes -protects spread of infection by compartmentalization -derived from dorsal mesentery f. blood supply -extremely rich blood supply, mucous membrane produces 2.5 L/d of secretion daily -arterial celiac trunk—1st midline branch of ab aorta (LR gastric, LR gastroepiploic) g. histology -muscularis layer—3 layers of smooth muscle -outer longitudinal -middle circular layer which is thickened to form pyloric sphincter -inner oblique -rugae—folds -goblet cells—secrete mucus -parietal cells—HcL (pH=2)—denature protein and kill bacteria -chief cells—pepsinogen—HcL + pepsinogenpepsin, lipase -gastrin cells—within pyloris, secrete gastrin (hormone), stim HCL secretion from parietal cells -intrinsic factor—required for B12 abs in the small intestine, without B12pernicious anemia h. innervation—sympathetic vasomotor and pain fibers from celiac plexus, parasympathetic fibers to muscle wall and secretory areas from anterior and posterior branules of vagus trunks (after reform from esohagus and pass into abdomen with esophagus) 10/4/99 5. Small Intestine—p. 245 moore -segmental peristalsis—the constrictions occur in small segments -chyme -supported by mesentery which allows mobility and helps prevent kinks and twists -innervation—superior mesenteric plexus (autonomic) -venous drainage—(portal system)—superior mesenteric v.splenic v.hepatic v. a. Histology -mucosa—simple columnar epithelium (with microvilli—increase surface area) 30 -brush boarder enzymes (same as microvilli) -secreted by cells lining the mucosa -Enterokinase (gut activator)— -activates tripsinogentripsin (CHO and lipid breakdown) -also activates other enzymes -Lactase—digests lactose (disaccharide) into—(glucose and galactose) *-plicae circularis (can see with naked eye)—interior folds of the small intestine (mucosal wall)they stick inward to lumen (looks like a spring)—very well developed in jejunum. Plicae circularis has villi and microvilli -villi—microscopic folds of the mucosa (all for surface area) -lacteal—lymphatic vessel -blood capillaries—absorb monosaccharides and amino acids—most all nutrients absorbed at level of small intestine -goblet cells—within columnar epithelium and secrete mucus b. Duodenum (L1-L3)—mainly retroperitoneal—lies behind the peritoneal membrane—1st 10 inches of small intestine—C-shaped -curve surrounds neck of pancreas and lies on hilus and vessels of R kidney. Bile duct and portal vein lie behind. Deeply is separated from IVC by epiploic foramen (join greater and lesser sacs of peritoneum) -superior—passes posterior and to the right -descending -horizontal—L3 -ascending 31 Part of Duodenum Superior (1st part) anterolateral to L1 Anterior Posterior Peritoneum Gallbladder Quadrate lobe Descending (2nd part) right of L2L3 Transverse colon Transverse mesocolon Coils of small intestine SMA SMV Coils of small intestine Beginning of root of mesentery Coils of jejunum Bile duct Gastroduodenal a. Portal v. IVC Hilum of R kidney Renal vessels Ureter Psoas major Horizontal (3rd part) anterior to L3 Ascending (4th part) Left of L3 Right psoas major IVC Aorta Right ureter Left psoas major Left margin of aorta Medial Superior Inferior Neck of gallbladder Neck of pancreas Head of pancreas Pancreatic duct Bile duct Head of pancreas Head of uncinate process of pancreas SM vessels Body of pancreas -duodenal flexure (duodenum meets jejunum)—anchored to the diaphragm by the suspensory ligament of Treitz Hepatopancreatic Ampulla—recieves the common bile duct, pancreatic and bile secretions, opened and closed by the sphincter of papilla (Odi) Blood supply—hepatic a.(and gastroduodenal a. branch, branches from SMA Innervation—superior mesenteric plexus *draw cystic/bile ducts c. Jejunum and Ileum— -mobile with only two points of attachment, duodenal flexure and ileocolic junction -jejunum—3 feet long—larger lumen than ileum; thick plicae circularis -ileum—6 feet long—thin walled; contains Peyer’s Patches (seen under microscope) -vitamin B12, H2O, bile salts, and electrolyte absorption 6. Large intestine—p. 249 32 a. little or no food abs, but major role in water and electrolyte abs(K+, etc) --main role—regulates H2O loss b. Haustra—sac-like segments due to the contraction of longitudinal taenia coli m. (strip along length of large intestine); epiploic appendages—fat hanging off of tenia coli m. c. mucosa—simple columnar (like small intestine); many goblet cells (more than sm. Int.); no villi d. Cecum—ileocecal junction, valve prohibiting the back flow of chyme (ileocecal valve), blind pouch found in R iliac fossa, RLQ e. Vermiform appendix—finger-like projection p. 254 moore—acute appendicitis—obstruction of lumen (flu-like sx) -vague pain in the midline of the umbilical region (visceral pain fibers) -muscular rigidity, vomiting -within 1-2 h, moves into the RLQ (McBurney’s point)—lateral end of line b/t R anterior superior iliac spine and umbilicus), acute tenderness is felt from irritation of the parietal peritoneum and stimulation of somatic pain fibers -if rupture—could result in peritonitis f. Colon -ascending—up to liverhepatic flexure (R colic flexure) -transverse—splenic flexure (L colic flexure) -descending -sigmoid—s-shaped, its wall is most involved in diverticulosis, posses sigmoid mesocolon -R and L paracolic gutter—dead space—infection can fester here g. blood supply—branches of superior/inferior mesenteric a. drained by inferior mesenteric v. 10/6/99 7. Rectum (20cm) 8” -anal canal -arranged in highly vascular, longitudinal folds -hemorrhoids—masses of varicose veinsswelling, tenderness, blockage -anus—external opening of the anal canal—controlled by two sphincters -internal anal sphincter—smooth muscle—autonomic control -external anal sphincter—skeletal muscle—somatic control 8. innervation of colon -parasympathetic—vagus-all of ascending colon to mid transverse colon; the rest by sacral parasympathetic fibers (sacral plexus) -sympathetic—splanchnic nerves-greater and lesser splanchnic nerves (upper regions)—T9-T12, along with branches of L1-L3 and lumbar chain ganglia (lower region) 33 9. mesenteric arteries—p. 289 netter; p. 252 moore a. superior mesenteric—arises from aorta behind neck of pancreas -inferior pancreaticoduodenalpancreas and duodenum -middle colictransverse colon -ileocolicileum and ascending colon -right colicascending colon -intestinal arteriesto ileum and jejunum, respectively b. Inferior mesenteric -left colic artreytransverse and descending colon -sigmoid arterydescending and sigmoid colon -superior rectal arterytermination of inferior mesenteric arteryrectum ***Marginal artery—p. 252 moore—anastomotic arterial vessel, located along the edge of the mesentery, that connects branches of the superior mesenteric artery with branches along the colon, and finally to the superior rectal artery—along the outside edge of entire colon D. Abdominal Aorta—p. 303 moore 1. paired branches—p. 286 H?? a. inferior phrenic arteryto diaphragm and adrenals (also gives rise to the superior suprarenal) b. lumbar arterydeep into body of lumbar vertebra—feed spinal meninges, and posterior muscles, and skin of posterior lumbar region c. middle suprarenal arteryto adrenals (comes off of aort itself). Superior comes from phrenic artery; inferior comes from renal artery d. renalskidneys (most common organ that has variation) e. gonadalsto testes/ovaries 2. Aortic hiatus—site passes through diaphragm at the level of T12—thoracic duct, azygos vein, and also the greater splanchnic nerves go through here. E. Bifurcation of Aorta—feed lower limbs—p. 303 moore 1. at the level of L4 (refers to body of vertebra)—L and R common iliac arteries 2. at the level of the sacroiliac joint the common iliac splits—internal and external a. internal iliac artery (hypogastric)—branches to psoas major muscles(posterior abdominal wall), gluteal muscles, urinary bladder, prostate gland, ductus deferens, and branches to uterus and vagina b. external iliac -gives off the inferior epigastric vessels -becomes femoral and continue down leg—down femoral along the femoral cnal along with femoral vein and nerve 34 10/8/99 F. Venous drainage (IVC)—p. 394—formed at L5 by union of common iliac veins 1. enter up to thoracic cavity through diaphragm at level T8 2. ascends up the R side of aorta 3. receives R gonadal, R adrenal, R inferior phrenic v. -on L side these usually drain into L renal vein 4. also receives three hepatic veins—left and middle (sometimes unite), right -very short—1cm G. Cisterna Chyle—p. 307—origination of the thoracic duct, formed by the intestinal and lumbar lymph trunks—at level if L1 H. Portal system—p. 223—drains the contents of the stomach, intestines, spleen, pancreas, gallbladder 1. consists of SMV, IMV, splenic v.; also L and R gastric veins, and there tributaries—these unite to form the Portal vein 2. pathway—p. 223 I. Kidney—silent leader of body—retroperitoneal; typically lies at level of L1-L4. R kidney sits lower than L b/c of R lobe of liver. Surrounded by fibrous capsule and adipose tissue 1. Hilum—along medial border—region where vessels enter and exit (renal a.v., nerves ureter) 2. divided into outer cortex and inner medulla that contains renal columns from cortex and renal pyramids 3. innervation—renal plexus (majority is splanchnic nerves from thorax)—also parasympathetic in renal plexus 4. Aortarenal a.anterior and posterior a.’ssegmental a.’sinterlobar a.arcuate a. (at junction of cortex and medulla)interlobar a.glomerulus of nephronperitubular capillaryinterlobar v.arcuate v.interlobar v.renal v.IVC 5. nephron—functional unit of the kidney—1 million in each kidney—central area for BP control 6. Urine flow—in book -nephroncollecting ductsminor calyxmajor calyxrenal pelvisureterurinary bladderurethra J. Abdominal Nerves— 1. Lumbar Plexus (L1-L4)—p.298 a. subcostal nerve—T12—anterior to quadratus lumborum QL (muscle on posterior ab. wall)—runs b/t transverse and internal oblique muscles and supplies the abdominal muscles—lies just under rib 12 10/11/99 b. Iliohypogastric nerve—L1—emerges from lateral border psoas major, lies in front of QL and (runs between transverse and internal oblique and then to 35 external) innervates internal and transverse oblique muscles and skin above the pubis and gluteal region—p. 298 c. Ilioinguinal nerve—L1—lies in front of QL, runs between internal and external aponeuroses, follows spermatic cord—innervates internal and transverse oblique muscles and upper medial aspect of thigh and the skin of the external genitalia—goes right to iliac crest—use as marker to find other nerves d. Genitofemoral nerve (L1-L2)—lies on surface of psoas major muscle (has 2 branches)—exits through or near femoral canal. Innervates scrotum, labia majora, cremaster muscle, and middle anterior portion of thigh e. Lateral femoral cutaneous nerve-(L2-L3)—runs in front of iliacus muscle (runs through iliac fossa) behind inguinal ligament and innervates skin of anterior and lateral thigh f. Obturator nerve—(L2-L4)—follows medial border of psoas major muscle, enters thigh through obturator foramen. Innervates—adductor muscles of thigh (all medial muscles), cutaneous branches for medial skin of thigh; hip joint and knee joint—2nd in size to femoral nerve g. Femoral nerve—(L2-L4)—lies in groove between psoas major and iliacus and passes deep to inguinal ligament. Innervates—flexors of thigh, extensors of thigh, and skin of lower leg. 2. Autonomic plexus of abdomen—(thorax and abdomen—splanchnic is sympathetic; pelvic—splanchnic is parasympathetic) --receive branches from vagus (parasympathetic), thoracic and lumbar (sympathetic), and pelvic (parasympathetic) splanchnic nerve and sympathetic trunks a. Vagal trunks—enter abdomen with esophagus (T10)—quickly form anterior and posterior gastric branches to stomach and branch to celiac plexus. Vagus extends to mid-transverse colon b. Autonomic ganglia 1. Sympathetic chain—composed ascending and descending preganglionic sympathetic general visceral efferent (GVE) fibers and general visceral afferent (GVA) fibers and cell bodies of postganglionic sympathetic fibers. 2. collateral—(sympathetic ganglion)-celiac (solar plexus), superior and inferior mesenteric, aorticorenal (located near arteries) -formed by cell bodies of postganglionic fibers -receive pre fibers from splanchnic nerves c. Thoracic Splanchnic nerves—contain preganglionic GVE fibers from lateral horn and GVA fibers from dorsal root ganglion 1. greater—form from 5th – 9th sympathetic chain ganglia (enter celic ganglion) 36 2. lesser—form from the 10th – 11th sympathetic chain ganglia (enter along the aorticorenal ganglia) 3. least—form from 12th sympathetic ganglia (enters renal plexus) d. Lumbar splanchnic nerves—form from branches of 4 lumbar chain ganglia and contain preganglionic sympathetic (GVA) fibers. e. Pelvic splanchnic nerves—only splanchnic nerves carrying parasympathetic fibers—from S2-S4 spinal nerves and supply viscera and pelvis and descending colon and rectum. II. Other abdominal organs— 1. Liver -largest internal organ in the body (3.5-4 lbs in adult) -immediately beneath the diaphragm in the upper right quadrant -where nutrients absorbed in the digestive tract are processed (gluconeogenesis) and stored (CHO and lipids) -detoxification and inactivation of drugs and various substances -receives most of its blood supply from the portal vein (80%) and a smaller percentage from the hepatic a. (20%) -produces and secretes bile which is stored in the gallbladder prior to discharge into the duodenum -bile is important in emulsifying lipids in the digestive tract thus promoting easier digestion by lipase and absorption -synthesizes proteins: albumin, fibrinogen, prothrombin, and various lipoproteins a. Lobes of the liver --Right and Left Lobes -separated by Falciform Ligament—attaches liver to anterior wall of diaphragm -Ligamentum Teres—free border of the Falciform; remnant of the umbilical vein --Caudate Lobe—near the IVC --Quadrate Lobe—adjacent to the gallbladder—near portal vein! b. Histology—classic liver lobule 1. Structure units of the liver which can be seen under the light microscope.polygonal mass of tissue of hepatocytes grouped into interconnected plates 2. Hepatocytes—liver cells; epithelial cells --between cells—Bile canaliculus, the beginning of the bile duct 3. Central Vein—when it leaves the lobule it merges with the sublobar vein which will fuse forming Hepatic veins which empty into the IVC 4. Portal Space—present at the corners of the lobules --contains the portal triad: -venule (from portal v.) -arteriole (from hepatic a.) 37 -lymphatic vessel (bile duct?????????) 5. Sinusoids— -fenestrated capillaries (endothelial cells) which run toward the center and drain into central vein -each hepatocyte has microvilli which extend into the subendothelial space (Space of Disse) which permits easy exchange of nutrients -Kupffer cells are mononuclear phagocytic cells (macrophages) which metabolize aged erythrocytes -Ito cells are fat storing cells 6. Bile ducts -bile cnaliculusbile ductulesbile ducts -bile flows from center of lobule to periphery 7. Blood flows from the periphery to the center of the classic hepatic lobule c. Cirrhosis --a large number of lobules are destroyed and replaced with connective tissue --a result is the entry of ammonia into circulation --may be caused by chronic alcohol abuse, viral hepatitis, or other agents that may attack liver cells 2. Gallbladder a. a sac-like organ attached to the inferior surface of the liver b. variations are common c. blood supply ---cystic artery (branch of the right hepatic a.) ---venous drainage goes directly to the liver d. stores and concentrates bile from liver (30-50mL) ---Left and Right hepatic ductscommon hepatic duct ---cystic duct and common hepatic ductbiliary duct (passes behind the duodenum) --the cystic duct contains spirally arranged folds of the mucous membrane which allow for a common duct for bile entry and bile secretion ---biliary duct and pancreatic ducthepatopancreatic ampulla which opens at the duodenal papilla of the duodenum, the sphincter of the ampulla controls flow into the duodenum ---Cholecystokinin (hormone) --secreted by enteroendocrine cells (I-cells) of the small intestine mucosa --cause smooth muscle of the gallblader to contract and release bile --release of CCK is stimulated by the presence of dietary fats d. Histology --mucosa, highly folded, simple columnar epithelium --smooth muscle layer --connective tissue layer --serous membrane (visceral peritoneum) e. Cholelethiasis (gall stones), small hard mineral deposits (calculi) which can produce painful sx by blocking the cystic or common bile ducts 38 --cholesterol clusters together with bile salts and lecithin, supersaturation of cholesterol --chronic inflammation, pain, jaundiced --removed by high energy shock waves—extracorporeal shock-wave lithotripsy, surgery (cholecystectomy), oral ingestion of bile acids 3. Pancreas a. anatomy --positioned horizontally along the posterior abdominal wall (L1), retroperitoneal --adjacent to greater curvature of the stomach --uncinate process—tucked beneath the SMV --head—nestled in the curve of the duodenum, anterior to the IVC --body—overlies the superior mesenteric vessels and portal vein --tail—tapers toward the spleen b. blood supply and innervation— --innervated by the celiac plexus --arterial blood is supplied by the pancreatic branch of the splenic artery (celiac trunk) and pancreaticoduodenal branches of the SMA --venous drainage by the splenic and SMVHepatic Portal Vein c. endocrine function (islets of langerhans) --innervated by the autonomic nervous system --A-cells—secrete glucagon into the blood—glycogenolysisincreased blood glucose --B-cells—secrete insulin into the blood—gluconeogenesisdecreased blood glucose. Diabetes can result from an autoimmune disease in which antibodies “tag” Bcells to be destroyed --D-Cells—secrete somatostatin—inhibits islet hormone release d. Exocrine function—acini --intercalated ducts --centroacinar cells—pale staining --acinar cells --secrete pancreatic juice: water, bicarbonate, digestive enzymes (zymogens) --amylase --lipase --trypsinogen—enterokinasetrypsin --chymotrypsinogen—trypsinchymotrypsin --prophospholipase—trypsinphospholipase --secretion stimulated by: --secretin—ocurs in response to fall in duodenal pH (<4.5); stimulates pancreatic bicarb production which neutralizes chyme from stomach --cholecystokinin—stimulates secretion of digestive enzymes --Vagus 39 e. Pancreatitis—infl of the pancreas. Could be caused by a reflux of pancreatic juice and bile from the duodenum 4. Spleen a. lymphatic organ about the size of the palm --located in the left hypochondrium (LUQ) and follows the 10th rib --Hilus—where vessels enter --not palpable unless enlarged (dull percussion), if ruptured massive blood loss occurs b. blood supply—splenic artery (celiac trunk); splenic vein (Portal V.) c. functions --fetus—hematopoiesis --adult—not a vital organ, filters the blood, destroys old erythrocytes, recycles iron from hemoglobin, produce lymphocytes d. histology --blood flow—splenic arterytrabecular a.central a.(enveloped by a sheath of lymphocytes, Pariarterial Lymphatic Sheath)penicillar Arteriolessinusoids (red pulp sinuses), fenestrated endotheliumred pulp v.trabecular vsplenic vein --white pulp—mainly T-lymphocytes around the Central A. --mainly B-cells in nodules --activated B-cells migrate to the center of the nodule and divide forming plasma cells (release antibodies into the sinuses) and B-memory cells --marginal zone --between the white and red pulp --plays a significant role in filtering the blood by removing antigenic debris --red pulp (splenic cords) --reticular cells, lymphocytes, plasma cells, RBC, platelets, granulocytes, etc. --macrophages will engulf and digest old RBC’s -life span of RBC—120d -Hb broken down, globin is recyled, iron is released and transported in the blood (transferrin) to bone marrow where it is reused (erythropoiesis) --the iron free heme is metabolized to bilirubin and excreted in the bile (jaundice) e. leukemia --splenomegaly --anemia --nucleated RBC and immature granulocytes --spleen may return to its fetal role (hematopoiesis) 40 f. connected to stomach by dorsal mesentery (gastrosplenic ligament) and to kidney by lienorenal ligament) 5. Adrenal glands -endocrine—superior pole of kidney a. blood supply -arterial—branches of the inferior phrenic a. and renal a. -venous drainage—IVC on right and Renal v. on left b. Medulla (chromaffin cells) -secrete epinephrine and norepinephrine—vasoconstriction, change in heart rate, increased metabolism and increased serum glucose c. Cortex -controlled by adrenocorticotropic hormone which is released by the anterior lobe of the pituitary -zona glomerulosa—secrete mineralocorticoids (stim sodium absorption) and androgens -zona fasciculata and zona reticularis—secrete glucocorticoids (cortisol and corticosterone) --increased fat, protein, and CHO metabolism by the liver --inreases catabolism outside the liver --suppresses the immune system by decreasing the number of circulating lymphocytes 10/11/99 PELVIS—most all structures innervated by pudendal nerve (main nerve in pelvis) I. Perineum and pelvis A. Perineum—p. 392—(below pelvic organs—from pelvic diaphragm to skin)region that is bounded by the pelvic outlet that lies below the pelvic diaphragm(forms floor and supports pelvic viscera and is composed of muscles(fig.a p. 392) including levetor ani m. and coccygeus m.) --anteriorly—arcuate pubic ligament and pubis symphysis --posteriorly—coccyx --anterolaterally—ischiopubic rami --laterally—ischial tuberosity --posterolaterally—sacrotuberous ligament --floor—skin and fascia --roof—pelvic diaphragm --p. 390—divided into anterior urogenital triangle and posterior anal triangle by a line connecting the two ischial tuberosities B. Anal Triangle—chung p. 198 41 1. Ischiorectal (ischioanal) fossa --p. 400—pudendal canal—contains inferior rectal nerves and vessels (from pudendal n. and vessels). Leaves pelvis through greater sciatic foramen and enters perineum through lesser sciatic foramen --ischiorectal fat—cushion and holds tight together 2. Muscles of anal triangle—p. 198 chung --obturator internus—laterally rotates thigh --sphincter ani externus—form superior aspect of anus --levetor ani—support and raise the pelvic floor --coccygeus—support and raise the pelvic floor --levetor and coccygeus—o: ischial spine bone; I: coccyx bone 3. Rectum—p. 386—part of the large intestine starting at the sigmoid colon to the anal canal—follows curve of sacrum and coccyx --Blood supply— --superior rectal artery—from inferior mesenteric --middle rectal artery—from internal iliac --inferior rectal artery—from internal pudendal --veins—superior rectal veinsinferior mesentericportal system(above the pectinate line). Below the pectinate line (very small area) veins drain into caval system. --Anal canal—p. 386 ---upper 2/3—visceral innervation portion—belongs to intestine ---lower 1/3—somatic innervation portion—belongs to peritoneum ---contains: -anal columns—longitudinal folds of mucosa -anal valves—connect lower ends of the columns -anal columns and anal valves provide protection from stress -pectinate muscles—follows anal valves (connects the columns) --internal anal sphincter—smooth muscle --external anal sphincter—skeletal muscle --hemorrhoids—dilation of inferior and middle rectal veins due to lack of support from surrounding tissue and absence of valves in inferior mesenteric vein (varicose veins) --innervation—autonomic nervous system—pelvic splanchnic nerves(parasymp) and pudendal n. (symp)—look up C. Urogenital triangle—p. 389-90 1. bounded by urogenital diaphragm (skeletal muscle) and the superficial perineal fascia 2. Inferior fascia of urogenital diaphragm is the perineal membrane—triangular sheet of connective tissue—found spanning the two ischial pubic rami 3. Urethra—passes through the urogenital diaphragm 4. Sphincter urethrae—skeletal muscle—controls micturation 42 5. Perineal body—tendenous tissue—central tendon of the perineum—runs b/t anal canal and vagina / bulb of penis in male—serves as a site for other muscles to attach D. External Male Genitalia—p. 365—sagittal section 1. Scrotum—skin pouch that holds testes and contains dartos muscle (smooth muscle)—responds to temperature --blood supply from internal pudendal a. --innervated by branches of lumbar plexus (ilioinguinal, genitofemoral, femoral cutaneous), and pudendal nerve 2. Testes— --covered by peritoneal serous sac—tunica vaginalis (inner) --tough fibrous coat—tunica albuginea (outside) --divided into lobules filled with seminiferous tubuleswhere spermatogenesis occurs (end to end—700’) 3. Epididymis—sperm storage tube and maturation area for sperm (need to go there or won’t function)—lies on posterior superior border of testes. Forms into ductus deferens which will run up into inguinal canal and pass through the deep inguinal ring. In the abdominal cavity it will ascend anteriorly and over superior portion of bladder and wrap around posterior bladder and connect with duct—form ejaculatory duct within seminal vesicles 4. Penis --three masses of erectile tissue arranged in columns—highly vascular --two corpus cavernosum—contain deep dorsal artery (from internal pudendal a.) --one corpus spongiosum—contains urethra --glans penis termination covered by prepuce— --blood supply from superfiscial dorsal a. (from internal pudendal a.) --urethral artery (from internal pudendal a.) --venous drainage by deep (to prostatic plexus) and superficial (to femoral through superficial pudendal) veins --innervation—branches of pudendal n. (S2-S4) E. External Female Genitalia 1. Perineal Membrane—reduced in size due to vagina and dilation accomadations of childbirth --small fibrous arch (attachment site of the crura of the clitoris) 2. vagina—birth canal from vestibule to cervix. Innervation—pudendal nerve --blood supply from pudendal a., uterine a., vaginal a., --all of which branch from internal iliac a. --hymen—thin skin-like membrane covering the opening to the vagina 3. urethra—external opening—opens onto region b/t labia minora (vestibule) --just anterior to vaginal opening 4. clitoris—erectile tissue formed from same tissue as penis --glans clitoris—derived from corpus cavernosum 5. Vestibule—opening b/t labia minora, contains vaginal and urethral openings --labia minora—innermost—encircles the glans clitoris (superiorly) and forms prepuce—two thin folds of skin 43 --labia majora (same embryologic tissue that forms scrotum)—two fatty longitudinal folds of skin fuse anteriorly to form mons (fat pad) over pubic symphisis, round ligament of uterus extends to and ends in labia majora. F. Urinary Bladder—p. 360 1. rests on pubic symphisis and floor of pelvis below peritoneum. Made of smooth muscle (detrusor muscle) and lined with transitional epithelium (stretch out like squamous and come together like cuboidal). Pregnant—push down on bladder— decreased volume capacity 2. internal surface folded except for smooth triangular trigone—angles contain the ureter openings and the urethra opening 3. blood—branches of internal iliac a. v. 4. innervation—only pelvic structure that is not innervated by the pudendal nerve—branches from inferior mesenteric plexus(symp) and parasympathetic branches from S2-S4 (pelvic splanchnic) will cause micturation G. Male pelvic organs—p. 365 1. ductus deferens—enters pelvis at deep inguinal ring. Join with duct from seminal vesicles to from ejaculatory duct which will continue and open into prostatic urethra 2. seminal vesicles—2—lie at base of bladder and have tapered end --produce alkaline fluid and nutrients (fructose)—fluid makes up 60% of semen 3. prostate (common ca)—located inferior to male bladder and surrounds prostatic urethra and ejaculatory duct that empties into urethra --secretes alkaline fluid and enzymes to assist sperm motility—30% of semen 4. bulbourethral glands—2—cowper’s glands—pea size glands, inferior to prostate --secrete mucus during initial sexual stim—neutralize acidic urine 10/15/99 5. Erection—due to parasympathetic nerve stimulation which dilates arteries, compresses veins and contraction of bulbospongiosis and ischicavernosus muscles 6. Ejaculation—due to sympathetic fibers to smooth muscle of tract 3 mL—100 million sperm. H. Female pelvic organs—p. 370, 71,74 1. Broad Ligament—2 layers of peritoneum from lateral margin of uterus to pelvic wall—contains oviduct, overian vessels, round ligament, ureter 2. Ovaries—alternate ovulation each cycle—posterior aspect of broad ligament— attached by mesovarium (fold of peritoneum) to broad ligament --suspensory ligament of ovary—extends from ovary to the lateral wall of the pelvis and contains the ovarian artery 44 --ligament of ovary—extends from ovary to uterus—is continuous with the round ligament of the uterus --B.S.—ovarian arteries from the aorta. Venous drainage from pampiniform plexus (venules)gonadal v.’sIVC on right, renal on left 3. Oviduct—infundibulum contains fimbria and ampulla—both are site of fertilization --pathway for embryo to reach uterus—4-5d for embryo to reach uterus (morulablastocyst) --B.S.—ovarian arteries and uterine arteries (from internal iliac) --ectopic—90% will abort first week 4. Uterus—organ of gestation—lies above bladder --fundus, body, cervix (most common ca) --rectouterine pouch—pouch of Douglas—area b/t uterus and the rectum --B.S.—uterine arteries (from internal iliacs), venous drainage—uterine v.internal iliac v.common iliac vIVC (L5) --round ligament—from body of uterus to pelvic brim and thru inguinal canal to fat of labia majora (remains of gubernaculum) --cardinal ligaments—extend from cervix and vaginal fornix to pevic fascia—for stabilization 5. Vagina—muscular tube that serves as birth canal --B.S.—uterine a. and v. I. Intrenal iliac branches—4cm long (before give off branches), crossed anteriorly by ureter --variable in sexes—p. 352, 350 1. Posterior division -iliolumbar a.to iliacus m and psoas major m. -lateral sacral a.thru sacral foramen (posterior) to meninges and skin over sacrum -superior gluteal a.gluteal m. 2. Anterior division -inferior gluteal a.piriformis m -internal pudendaljust about everything -umbilical a.bladder, vas deferens, prostate, vagina -obturator a.thigh muscles (adductors)--medial -uterine a.uterus 45 10/18/99 I. Neck—p. 999 A. Superficial Fascia (outlined in yellow) 1. composed of areolar adipose; platysma muscle—within superficial fascia B. Deep Fascia (outlined in green) 1. Superficial layer—encloses SCM and trapezius m.; parotid and submandibular glands 2. Prevertebral layer—encloses the vertebral column and associated muscles (erector spinae m.), scalenes, and splenius capitus 3. Carotid sheath (outlined in orange) -contains common carotid a., internal carotid a., internal jugular v., and vagus n. (X). -attaches to the base of the skull 4. Pretracheal layer (outlined in purple) -encloses the thyroid, trachea, and esophagus **Triangles—the spaces between the neck muscles (SCM divides the triangles) C. Posterior Triangle—chung p. 253 1. lies in the lateral aspect of the neck 2. Apex is just posterior to the mastoid process near attachments of SCM and trapezius. Base is the clavicle; borders formed by the opposing margins of SCM and trapezius m. Roof is platysma m., floor is splenius capitus, levetor scapula, and scalenes p. 1006 3. Contains external jugular v. (crosses over SCM), scalene m., cutaneous branches of cervical plexus (C1-C4), junction of internal jugular and subclavian v., transverse cervical and suprascapular a. (thyrocervical trunk, beneath internal jugular vein), suprascapular n. from brachial plexus, spinal accessory n. (passes thru jugular foramen and supplies (SCM and trap), trunks brachial plexus (C5-T1) and subclavian a. that pass between ant. and middle scalene, phrenic n. 4. Subdivided into occipital triangle and subclavian triangle by posterior or inferior belly of the omohyoid m. 5. Ant., mid., post. scalene m., innervated by lower cervical C5-C8, elevates ribs o: cervical transverse process I: 1st rib (anterior and middle); 2nd rib (posterior) A: accessory inspiratory muscles 46 D. Anterior Triangle 1. bounded by SCM m.; anterior midline of the neck; inferior boarder of the mandible 2. apex—suprasternal notch; roof—platysma muscle 3. contains transverse cervical n., anterior jugular v., facial n., larynx, trachea, hyoid bone, muscles—digastric, omohyoid, thyroid) 4. subdivided into digastric triangle (submandibular triangle); submental triangle; arotid triangle; muscular triangle E. Muscles of the anterior triangle 1. Suprahyoid group—above hyoid—action: elevate hyoid, depress mandible a. digastric m.—p. 1004 --anterior belly o: digastric fossa of mandible I: body of hyoid I: trigeminal n. --posterior belly o: mastoid notch I: body of hyoid I: fascial n. b. o: I: I: mylohyoid m—p. 1014 mandible body of hyoid trigeminal n. c. o: I: I: stylohyoid m.—p. 1013 styloid process body of hyoid fascial n. 47 2. infrahyoid group—depress hyoid and larynx a. o: I: I: sternohyoid m.—p. 1013 sternoclavicular joint hyoid bone ansa cervicals (loop nerve structure from branches of C1-C3) b. Omohyoid m.— --inferior belly o: suprascapular notch I: intermediate tendon (in fascia of posterior tendon) I: ansa cervicals n. --superior belly o: intermediate ligament I: hyoid I: ansa cervicals c. o: I: I: thyrohyoid m. (superior)—under sternohyoid thyroid cartilage (like tape but continuous) hyoid bone C1 via hypoglossal d. sternothyroid m. (inferior)—beneath sternohyoid, continuous with thyrohyoid o: manubrium I: thyroid cartilage I: ansa vervicals n. 10/20/99 F. Cervical Plexus—ventral rami of C1-C4 p. 1010—1. Ansa Cervicalis—nerve loop formed by the joining of roots C1-C3. Innervates various neck muscles. 2. Phrenic nerve—C3-C5 --lies on anterior surface of anterior scalene muscle, passes into thorax deep to subclavian vein between mediastinal pleura and fibrous pericardium. --innervates—diaphragm, pericardium, mediastinal pleura --*small branches to other neck muscles—longus cap., SCM, trap., scalene, levetor scapula. 3. Cutaneous branches of cervical plexus --a. lesser occipital n. (C2)—ascends along posterior boarder of SCM to the scalp behind the auricle. --b. Great auricle n. (C2-C3)—ascends up neck close to lesser occipital— over surface of SCM to skin around auricle and over parotid gland 48 --c. Transverse cervical n. (C2-C3)—loops around posterior boarder of SCM and innervates skin of anterior cervical triangle (comes out under SCM and goes across neck) --d. Suprascapular n. (C3-C4)—emerge from the posterior boarder of SCM. Quickly divides into many small branches (anterior, middle, posterior). Goes to skin over clavicle and shoulder. G. Brachial Plexus—p. 709-710—formed by the ventral primary rami (C5-T1) and passes between anterior and middle scalene muscle --Randy Travis Drinks Cold Beer 1. Root branches a. Dorsal scapular n. (C5)—emerge behind the anterior scalene, runs backwards thru the middle scalene, and then deep to the trap along medial boarder of scapula.—innervates levetor scapula and rhomboids b. Long thoracic n.—pierce middle scalene muscles, runs posterior to main bulk of brachial plexus along axilla to serratus anterior muscle 2. Branches of upper trunk a. Suprascapular nerve n. (C5-C6)—passes deep to trap m. and joins with the suprascapular a., thru suprascapular notch to supra and infra spinatous m.’s. b. Nerve to subclavius m. (C5)—descend anterior to main bulk of brachial plexus to the subclavius m. inferior and posterior to the clavicle. H. Sympathetic Trunk in the Neck—ascends vertically on surface of longus capitus m and posterior to carotid sheath, has gray but no white rami communicans --contains— 1. superior ganglion (level C2)—branches to carotid plexus, heart, and pharyngeal plexus 2. Middle ganglion (level C6)—branch to the heart 3. inferior ganglion (C7)—fuse together with first thoracic ganglion and branch to the heart. I. Accessory n.—formed by cranial roots from medulla oblongata and spinal cord (C1-C3) --lies on levetor scapulae m., in posterior triangle --innervates—trap and SCM, also branches to pharynx and larynx 49 J. Blood vessels of neck—p. 1017 1. Subclavian artery—branch from brachiocephalic a. on right, aortic arch on left a. Vertebral artery—1st branch, passes thru transverse foramen C6-C1 thru foramen magnum b. Thyrocervical trunk— --inferior thyroid—to thyroid—gives rise to ascending cervical a. runs up surface of anterior scalene just medial to phrenic nerve --transverse cervical—laterally across the anterior scalene and goes deep to the trapezius --suprascapular a—passes across the anterior scalene; found below but parallel to transverse cervical a.; runs to the supraspinus fossa thru the suprascapular notch c. Internal thoracic—descends thru thorax posterior to the upper 6 costal cartilages d. Costocervical trunk—arises lateral to thyrocervical trunk --deep cervical—ascends up the neck lying over top of splenius capitus, it anastomizes with occipital a. --superior intercostal—descends to form 1st and 2nd posterior intercostal a’s e. dorsal scapula—arises from subclavian or transverse cervical and runs along medial boarder of scapula 2. Common carotid arteries—p. 1017/1015—does not branch in neck, branches on the head—right from brachiocephalic, left from aortic arch—bifurcates at level of upper boarder thyroid cartilage --carotid body—lies at bifurcation point. Chemoreceptor of blood chemicals. Innervated by vagus and glossopharyngeal n. --carotid sinus—at base of internal carotid—baroreceptors for BP. Innervated by vagus and glossopharyngeal n. 50 10/22/99 a. Internal Carotid a.—p. 893 --no branches in neck --enters carotid canal—give rise to opthalmic artery as well as anterior and middle cerebral arteries. b. External Carotid a.—runs from bifurcation to neck of mandible where enters Parotid gland and divides into superficial temporal a. (scalp over temporal and parietal) and maxillary a. (skin over maxilla) --superior thyroid a.—arises at level of hyoid and gives several banches --lingual a.—branch above superior thyroid a. –goes to tongue --facial a.—arises near level of angle of mandible to anterior face, deep to posterior digastric and gives off several branches—some of which anastomize with branches of opthalmic artery (from internal carotid) to form a connection between internal and external carotid a.’s --ascending pharyngeal a.—arises at the medial origin of external carotid a. Ascends up neck b/t internal carotid and wall of the pharynx to the base of the skull --occipital a.—arises just opposite of the fascial a. just above hyoid; runs deep to posterior belly of digastric m. and feed skin over the occipital bone --posterior auricular a.—arises above posterior digastric belly and runs superficial b/t the mastoid process and external acoustic meatus --transverse facial a.—arises from superficial temporal to feed skin over zygomatic 3. Veins—p.1008—very variable—connecting branches—xtra veins a. retromandibular v.—formed from union of superficial temporal v. and maxillary v. --posterior branch—joins posterior auricular v. to form external jugular v. External jugular v. ends in subclavian v. Just before external jugular empties into subclavian it receives anterior jugular v., suprascapular v., and transverse cervical v. --anterior branch—joins facial vein to form common facial vein and common facial vein empties into internal jugular. b. Internal jugular (p. 282 Chung)—begins in jugular foramen (continuation of sigmoid sinus)—blood pools. Internal jugular vein descends in carotid sheath and drains brain, neck, and face. c. Communicating branches—veins that connect the above major veins 51 10/25/99 III. Nerve supply to the face A. Facial nerve—p. 863 1. exits stylomastoid foramen ( gives off posterior auricular n. to occipital, stylohyoid, and posterior digastric m.) and enters parotid and produces 5 branches --temporal --zygomatic --buccal --marginal mandibular --cervical branches The Zoo Buys Many Chimps B. 1. 2. 3. Trigeminal nerve—skin of face—p. 860 Opthalmic division—I: area above upper eyelid and dorsum of nose (purple) Maxillary division—I: face below the eyes and above the upper lip (blue) Mandibular division—I: inervates face below the lower lip (pink IV. Brain—p. 866 A. B.S.—internal carotid and vertebral a.’s 1. Internal carotid a.—enter skull thru carotid canal in petrus portion of the temporal bone and enters cranial fossa thru foramen lacerum a. gives off opthalmic a. to orbit b. terminates at optic chiasma by dividing into anterior cerebral a.(orbital surface frontal lobe medial cerebral hemisphere except occipitals) and middle cerebral a. (lateral surface of cerebral hemisphere), and posterior communicating arteries (connect internal carotid and vertebral) c. also give branch to pituitary 2. Vertebral Artery—enter cranial cavity thru foramen magnum a. R and L join at anterior aspect of brain stem to form a single basilar a. Ascends short distance—divides into 2 posterior cerebral arteries (feed occipital and temporal lobes --branches of basilar a.—pontine, anterior-inferior cerebellar, labyrinthine (ear), superior cerebellar—p. 895 b. branches from both R and L vertebral a.’s form anterior spinal a. c. Posterior-inferior cerebellar a.’s will branch to form the posterior spinal artery 3. Circle of Willis—p. 894 (circulosis arteriosis)—formed by posterior cerebral, posterior communicating, internal carotid, anterior cerebral, and anterior communicating --provides multiple routes for collateral blood circulation 52 B. Cranial Sinuses—p. 878/262chung—very huge vein—all drain blood from brain and enter into internal jugular v. 1. Superior sagittal sinus—p. 881—lies in superior margin of falx cerebri 2. Inferior sagittal sinus—lies in inferior margin of falx cerebri 3. Straight sinus—lies in tentorium cerebelli 4. Transverse sinus—runs along the edge of the tentorium cerebelli --diploe veins—lie in spongy bone and connect to dura sinus --emissary veins—connect venous sinuses to diploe v. and veins in scalp C. Brain regions—see handout—lobes of cerebrum—2 parietal, 2 temporal, 1 frontal, 1 occipital. Cerebellum 1. falx cerebri—separates the two parietal lobes, found in the longitudinal fissure and attaches to crista galli (of ethmoid) 2. falx cerebelli—separates the two halves of the cerebellum 3. tentorium cerebelli—seperates cerebellum from cerebrum D. Ventricles—Route of CSF 2 lateral ventricles join together with 3rd ventricle which surrounds thalamus. They are connected by the interventricular foramen 4th ventricle—anterior to cerebellum cerebral aqueduct—canal from 3rd ventricle to 4th ventricleto spinal cord thru central canal E. Functional areas—see handout— --Broca’s area—speech V. Cranial nerves A. Olfactory I—CE—cribiform plate, synapse in olfactory bulb, sensory for smell by way of bipolar neurons. Goes directly to area of interpretation—NO THALAMUS B. Optic II—CE—optic canal, synapse in visual cortex, sensory for vision C. Occulomotor III—CE—superior orbital fissure, motor—control superior and inferior and medial rectus muscles, inferior qblique muscles, levetor palpebrae, and constriction of the pupil (ciliary muscles D. Trochlear IV—CE—superior orbital fissure; motorsuperior oblique muscle (eye) E. Trigeminal V—CE—superior orbital fissure, foramen rotundum, and foramen ovale; motormuscles of mastication (masseter and temporalis); sensorygeneral sensation of skin and head F. Abducens VI—CE—superior orbital fissure; motor to lateral rectus m (eye) G. Facial VII—CE—stylomastoid foramen; motor for facial muscles (digastric, stylohyoid); viscerallacrimal gland, salivary secretion; sensory for tasteon the anterior 2/3 of tongue 53 H. Vestibulocochlear VII—does not leave skull; sensory for equilibrium and hearing I. Glossopharyngeal IX—CE—jugular foramen; motorelevate pharynx (stylopharyngeas m) and larynx; visceralglands (parotid); sensory for taste on posterior 1/3 of tongue J. Vagus X—CE—jugular foramen; motormuscles of pharynx and larynx; sensory from pharynx and larynx; visceralthoracic and abdominal organs K. Accessory XI—CE—jugular foramen; motorSCM and trapezius m. L. Hypoglossal XII—CE—hypoglossal canal; motormuscles of tongue movement EXAM II TO HERE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 10/29/99 ARM—p. 677 surface anatomy I. Arteries of the upper limb a. Axillary Artery—p. 702 1. Begins at outer boarder of 1st rib to the inferior boarder of teres minor m.—can be divided into three parts by the pec minor m. 2. Branches— --Superior thoracic a.—supplies the 1st and 2nd intercostal space and both of the pec muscles --thoracoacromial a.—comes off axillary near medial boarder of pecminor and branches to—pectoral a., acromial a., clavicular a., deltoid a. --lateral thoracic a.—follows lateral boarder of pec minor, supplies serratus anterior m. and breast tissue (sometimes has small branches to pec muscles) --subscapular a.—largest branch; arises at lower boarder of the subscapularis m.and follows the lateral boarder of the scapula; branches will anastomize with branches of subclavian -thoracodorsal a.—latissimus dorsi m. -circumflex scapular a.—to suprascapular a. anastamoses --p. 704-705 --Anterior and posterior humoral circumflex (extensor compartment)— around neck of humerus—check these arteries if bleeding fracture. They form an anastomotic circle around the surgical neck of the humerus; anterior is smaller; posterior follows axillary nerve thru quadrangular space b. Brachial Artery—p. 750—extends from inferior boarder of teres major m. to bifurcation in the cubital fossa—into radial and ulnar a.’s --lies on triceps brachii m. and brachialis m., medial to the coracobrachialis m. and is acompanied by the basilic vein --lies in center of cubital fossa, lateral to the median nerve --provides many muscular branches and a nutrient a. 54 --Branches— --profunda brachii (deep brachial a.)—entensor compartment -descend posterior of arm (dorsal surface) -divide into middle collateral a. (continues posteriorly to anastamose with interosseus a.) and radial collateral a.(accompanies radial nerve in anterior compartment of the forearm) --superior ulnar collateral a.(branch from brachial)—follows ulnar n. and anastamose with the posterior recurrent branch of the ulnar a. (need this extra blood for the joint) --inferior ulnar collateral a.—arises above the elbow and descends anterior to the medial condyle of the humerus and anastamose with branch of ulnar a. 11/3/99 --anatomical reference—upper limb = entire arm; arm = structures along humerus; forearm = bottom C. Radial artery—p. 750 1. Lateral branch of brachial a. in cubital fossa. Runs laterally under brachioradialis m (bifurcates at midpoint of wrist) 2. divides in hand into princeps pollicis a (to thumb) and deep palmar arch (which will branch to fingers) 3. Branches—p. 773 --radial recurrent a—arise just below origin of radial artery and ascends to anastamose with radial collateral branch artery of the profunda brachii a. --palmar carpal a—to wrist --superficial palmar a—to palm D. Ulnar artery—p. 750 1. medial branch of brachial artery in cubital fossa 2. descends to medial side of forearm under cover of flexi carpi ulnaris muscle. Continues into the hand where it divides into the deep and superficial palmar arteries that anastamose with the radial artery counterparts. (ulnar and radial arteries connect deep and superficial in the hand) 3. Branches— --anterior and posterior ulnar recurrent artery—anastamose around the elbow joint with the inferior and superior collateral arteries --superficial and deep palmar arch a—anastamoses with radial artery counterparts --common interosseus a—arises from lateral side of ulnar artery just after its origin—divides into anterior interosseus a and posterior interosseus a -anterior interosseus a—pass down on anterior surface of the interosseus membrane. -posterior interosseus a—pass deep and down dorsal aspect of forearm -both ant and post interosseus a’s anastamose at the wrist 55 II. Veins of the upper limb—p. 755 A. Superficial Veins 1. cephalic v—begins as continuation of dorsal venous network of hand and ascends on lateral side of the forearm, across deltopectoral groove and penetrates deep to axillary v. 2. basilic v—begins at dorsum of hand—ascends up the postero-medial arm, anterior to the medial epicondyle of the humerus, penetrates deep (just above the elbow joint) to join up with venae comitantes of the upper arm near brachial a. –joins with brachial v. to form axillary v. 3. Median cubital v—joins cephalic v and basilar v at level of elbow joint (dorsum) 4. median antebrahial v—begins in palmar venous network—ascends anterior forearm and join with median cubital v. (palmar) B. Deep veins— 1. deep and superficial venous arches—accompany their arterial counterparts in hand 2. radial veins, ulnar veins, and brachial veins follow arterial counterparts and ascend with axillary v. 3. axillary v—begins lower boarder of teres major as continuation of basilic v—ascends along the medial side of the axillary artery, receives venous branches corresponding to axillary artery branches; also receives cephalic vein III. Nerves of the upper limb—p. 709, 710, 713—draw A. Brachial plexus—C5-T1 --roots pass between anterior and middle scalene m’s --covered by extension of the prevertebral fascia (axillary sheath) with the axillary artery and vein --composed of roots, trunks (upper, middle, lower), divisions (3 post; 3 ant), and cords (lateral, posterior and medial) 11/5/99 1. Root branches --dorsal scapular n. (C5)—pierce middle scalene to posterior triangle, descend deep to levator scapula m and rhomboids --long thoracic n. (C5-C7)—descends posterior to main bulk of brachial plexus over surface of anterior scalene m. (I: serratus anterior m.) 2. Upper trunk branches—p. 710 --suprascapular n. (C5-C6)—runs laterally across posterior cervical triangle deep to trapezius m. through suprascapular notch to shoulder joint and infra and supra spinatus m.’s. --nerve to subclavius m. (C5)—runs to subclavius m. (anterior to main bulk of brachial plexus) 56 p. 710—Divisions—3 anterior and 3 posterior 3. Lateral cord branches— --lateral pectoral n. (C5-C7)—innervates pectoralis major m. --musculocutaneous n. (C5-C7)—p. 713 -pierces the corachobrachialis m. and descend b/t triceps brachii and brachialis m.m. -innervates all of the flexor m.’s in the anterior compartment of the upper arm -becomes the lateral antebrachial cutaneous n. in forearm 4. Medial cord branches— --medial pectoral n. (C8-T1)—innervate both pectoralis muscles --medial brachial cutaneous n. (C8-T1)—runs along medial side of axillary v.; innervates skin of the medial upper arm --medial antebrachial cutaneous n. (C8-T1)—runs b/t axillary a. and v. and then medial to brachial artery; innervates skin on medial side of forearm --ulnar n (C7-T1)—p. 714 -runs along medial aspect of arm, posterior to medial epicondyle of humerus; no branches in upper arm—branches start near elbow -enters hand lateral to pisiform and divides into superficial (skin of little finger and ledial side ring finger) and deep (to thumb) branch 5. Posterior cord branches—p. 714 --upper scapular n. (C5-C6)—to subscapularis m. --thoracodorsal n. (C7-C8)—runs b/h axillary a., follows thoracodorsal a. to latissimus dorsi m. --lower scapular n. (C5-C6)—to subscapularis m. and teres major m. --axillary n. (C5-C6)—mainly to deltoid m. and teres minor m.—thru quadrangular space --radial n.—largest; passes thru tringular interval; runs down posterior aspect of arm in radial groove—innervates triceps brachii m. 6. Branches of medial and lateral cords --median n. –major innervator of forearm (p. 713) -runs down antero-medial aspect of arm on medial side of brahial artery. -give off the anterior interosseus n. (forearm m.’s—flexor digitorum profundus, flexor pollicic longus, pronator quadratus) in cubital fossa -innervates all anterior muscles of the forearm except flexi carpi ulnaris m. -enters palm deep to retinaculum p. 782-783—innervation of the hand 57 11/8/99 IV. Hand—p. 775 A. Flexor Retinaculum—broad sheet of fibrous tissue over the anterior surface of the wrist. Most things enterthe hand deep to it 1. forms the carpal tunnel 2. entering palm superficial to retinaculum is ulnar n., ulnara., and tendon of palmar longus m. B. carpal tunnel formed anteriorly by the flexor retinaculum and posterior by the carpal bones --encases the tendons of the flexors and the median n. --carpal tunnel syndrome—damage to the median n—press on it—pain, etc. C. Extensor Retinaculum—p. 741 1. found on dorsum of wrist 2. wraps the extensor tendons 3. crossed by the superficial branch of the radial n. 4. individual sheaths wrap the tendon of each muscle—p. 765 --all of this surrounded by the extensor retinaculum—padding for movement—less friction and less wear D. Fascial Spaces—thenar space and midpalmar space—--p. 765 --filled with fat to be able to grip things better --fascial spaces are the central part of the palm deep to palmar aponeurosis 1. thenar space—lies b/t middle metacarpal bone and the tendon of the flexor pollicis longus 2. midpalmar space—lies b/t middle carpal bone and hypothenar eminance E. Thenar Eminance—p. 748—raised region b/t middle of wrist and base of thumb—composed of three thenar muscles (see in thumb injuries—pulls/twists/etc) --adductor pollicis brevis m. --flexor pollicis brevis m. --opponens pollicis m. --all supplied by the recurrent muscular branch of the median n. 58 11/10/99 F. Hypothenar Eminance—p. 768—region b/t middle of wrist and base of the little finger --three muscles --abductor digiti minimi m. (biggest—most lateral) --flexor digiti minimi brevis m. --opponens digiti minimi m. --innervation—deep branch of ulnar n. G. Anatomical snuff box—p. 748 --triangle bounded medially by tendon of extensor pollicis longus and laterally by tendon of extensor pollicis brevis and abductor pollicis longus --limited proximally by the styloid process of the radius --floor is scaphoid bone and trapezium bone and is crossed by the radial a. diagram p. 759—nerves of forearm 11/11/99—Miss High’s lab lecture Brachial plexus and neurological findings— --Carpal Tunnel Syndrome—repetetive motion disorder --typing --heavy lifting --damage to median and ulnar n. --linked to >10% IBW and sedentary lifestyle Sx— --numbness --dry hand—sympathetic-cholinergic causes sweatingthey are damaged so the hand will be dry --anxiety and hyperventilation will also cause tingling --if the numbness is across entire handsuggest PVD—not neurological damage Tests for CTS— --median nerve test—put 4th finger and thumb together—shouldn’t be able to break it --ulnar nerve test—hold paper b/t fingers (abduction) --finger adduction --grip strength *flex hand and compress median nervelose sensation in hand --synovial cyst—stir it up and it won’t reform --cell ody of motor neuron in lateral horn in nuclei --brachioradialis—flexor and supinator of forearm 59 --pressure on nervedeplete ATP and nutrientsstops working --Deep tendon reflexes— biceps brachii—C5-C6 triceps brachii—C6-C7 brachioradialis—C5-C6 --strike these and look for reflex 11/12/99 Lower limb—p. 523 I. Compartments of the thigh --extensor campartment—anterior --adductor compartment—medial --flexor compartment—posterior --separated by intermuscular septum p. 564 A. Fascia lata—p. 523—deep fascia that surrounds the muscles just like a sock 1. Attachments --superiorly—to Os Coxae (pelvic bone—ischium, ilium, pubis), inguinal ligament, and the gluteal fascia --anteriorly attached to patella and tibial condyles --posteriorly covers popliteal fossa to calf 2. laterally the fascia lata splits to enclose tensor fascia lata muscle belly which pulls on the iliotibial tract that extends to lateral condyle of the tibia 3. Saphenous opening—a hole just below the medial end of the inguinal ligament where the great saphenous vein will travel deep and join to the femoral vein (along with lymphatic vessels) covered by cribriform fascia B. Intermuscular septum—connect the fascia latae (plural) to femur 1. lateral (gluteus maximus attaches)—separates the anterior extensors from the posterior flexors (hams) 2. medial septum—separate the extensors from the adductors (medial) 3. Intermediate septum—separate the adductors and the flexors II. Anterior thigh structures—p. 542 A. Femoral triangle—bounded by— --superiorly—inguinal ligament --laterally—sartorius muscle --medially—adductor longus muscle --floor—iliopsoas muscle and pectineus muscle 1. Contains femoral n., a., v., and femoral canal --femoral canal—contains fat, CT, and lymphatic vessels --femoral canal—closed of at the abdominal wall by peritoneum— potential weak areafemoral hernia 60 --femoral canal is medial to the vesselsallows for expansion of the blood vessels 11/15/99 Lab exam—Tue, Dec 7—8-10/10-12 Lecture exam—Sat, Dec 11—1-4 Make-up quiz—Mon, Dec 6 2. Femoral Sheath—p. 542/544 --formed from transversalis fascia—closed at abdominal wall by peritoneum --contains femoral a., v., femoral canal, and the femoral branch of genitofemoral n. (L1-L2) --extends to the level of the saphenous opening B. Adductor canal—anterior thigh—p. 549 cross sx / p. 523 and 721 (cross of arm— KNOW THESE) 1. begins at the apex of the femoral triangle and ends at adductor hiatus— aperture in the insertion tendon of the adductor magnus m. that allows femoral vessels to pass thru popliteal fossa. 2. contains femoral a., v., and saphenous n. III. Arteries of the lower limb—p. 547—very similar to the arm A. superior and inferior gluteal a.’s—p. 561 1. arises from internal iliac a., enters buttocks thru greater sciatic foramen, above (superior gluteal a) and below (inferior gluteal a) pisiformis m., supply all gluteal muscles (inferior gluteal a. also supplies the flexor hamstrings) B. Obturator artery 1--arises from internal iliac a. in pelvis and passes thru obturator foramen then divides into anterior and posterior branches to supply the adductor muscles of the thigh 2--acetabular branch from posterior branch of obturator artery—supplies head of femur C. Femoral Artery 1. continuation of external iliac a. thru femoral triangle—femoral vein will be medial to the femoral a in thigh—then femoral vein lies posterior to the femoral artery in the popliteal fossa 2. continues as politeal a in lower leg 3. superficial branches— --superficial epigastric a—arises just inferior to the inguinal ligament and runs up towards the umbilicus—much smaller than the superior and inferior epigastrics 61 --superficial circumflex iliac a—runs up along side the inferior boarder of the inguinal ligament --external pudendal a—exits the saphenous ring, runs medially over the spermatic cord to scrotum (labia majora) and the groin 4. Deep branches— --deep external pudendal a—runs medially from the femoral a. to the peritoneum --profundus femoris a(deep femoral a)—arises from femoral a in femoral triangle -descends in adductor compartment and will anastamose with muscular branches of politeal a. (extra route of blood to foot) -gives off 4 muscular branches that pierce and supply adductor magnus and hamstrings -gives rise to medial and lateral femoral circumflex arteries—anastamose around the neck and head of the femur—both med and lat femoral circumflex give branches that ascend to anastamose with gluteal arteries and branches to cruciate anastamoses (links internal iliac and politeal a.s) internal iliac afemoral circumflex amuscular branches profunda femoris a.’smuscular branches of politeal a. --descending genicular a—arise just before the adductor hiatus— supply branches to the knee joint and skin on medial side of the thigh 11/17/99 D. Popliteal artery—p. 583 1. continuation of femoral artery in adductor hiatus—descends thru popliteal fossa (back of knee) to divide into anterior and posterior tibial arteries (occurs at lower boarder of the popliteal muscle) 2. Polpliteal a. (p. 574) gives rise to 5 genicular branches which wrap the knee E. Posterior tibial artery—p. 583—larger of the 2 1. continuation of popliteal a. 2. runs downward and medially with tibial nerve to the medial malleolus 3. gives off perineal a. (fibular a.) just after its formation a. descends thru posterior compartment of leg close to fibula to ankle b. produces muscular branches and a perforating branch thru interosseus membrane to antreior tibial a. 4. terminates by dividing in the foot into medial and lateral plantar arteries. Medial—big toe; lateral—forms deep plantar arch by joining up with the deep pedis a. 62 F. Anterior tibial artery— 1. formed at the popliteal bifurcation 2. passes thru opening in the interosseus membrane (anterior side of tibia) into anterior compartment 3. descends with deep perineal to medial side of ankle 4. gives rise to anterior, medial, and lateral malleolar arteries and anterior tibial recurrent a. back up to the knee joint 5. continues onto dorsum of foot as dorsal pedis a. G. dorsal pedis a.—p. 591 1. gives tiny dorsal branches to tarsals; metatarsals; and digits 2. terminates as the deep plantar artery which joins lateral plantar regions of the foot IV. VEINS OF THE LOWER LIMB A. superficial veins—p. 525 1. dorsal venous arch—receive all blood from both dorsal and plantar regions of the foot 2. great saphenous vein—originates in dorsal venous arch, continues anterior to medial malleolus and up medial side of the leg, behind medial condyles of the femur, to the saphenous opening where it penetrates to join the femoral vein (fossa ovalis—p. 525) a. near saphenous opening—veins corresponding to the femoral artery join here b. communicates with the deep veins of the leg by perforating veins with valves to control blood flow from superficial to deep—failure of valves = varicose veins 3. small saphenous vein— a. begins lateral and dorsal venous arch—ascends b/h the lateral malleolus with one of the sural nerves up the posterior surface of gastrocnemius m. to pierce the deep fascia of the popliteal fossa and join with the popliteal artery p. 525—diagram of deep veins—follow arterial counterparts 63 V. LYMPHATICS A. superficial vessels—p. 528 1. medial group—follows great saphenous vein 2. lateral group—follows small saphenous vein B. deep vessels—drain the lower leg and enter the popliteal lymph nodes-p.528b C. inguinal lymph nodes (superficial and deep) 1. superficial group—located subq near saphenofemoral junction—drain lower abdomen below the umbilicus, gluteal area, and external genitalia a. empty into external iliac nodes 2. deep group—lies deep on medial side of femoral vein a. receive lymph from lymph vessels surrounding femoral artery and vein b. empty into external iliac nodes as well VI. NERVES OF LOWER LIMB A. Obturator nerve—(L3-L4)—p. 530 1. anterior branch—descends between the adductor longus and adductor brevis m.m’s 2. posterior branch—descends between the adductor brevis and adductor magnus m.m’s 3. innervates—medial compartment of the thigh B. Femoral nerve—(L2-L4) 1. found in the femoral triangle 2. gives muscular branches to anterior compartment, articular branches to the knee and hip joint 3. divides into anterior division confined to the thigh and posterior division which sends saphenous nerve thru adductor canal and down medial side of leg to the foot C. superior and inferior gluteal nerves—L4-S2—p. 557 --enter buttocks thru greater sciatic notch above and below the piriformis m. --innervate the gluteal muscles D. posterior femoral cutaneous nerve—S2-S3—p. 557 --descend from below the piriformis m. to the skin of ass, thigh, calf, and the external genitalia (skin of) E. sciatic nerve—L4-S3—p. 553—larget nerve in the body 1--enter buttocks thru greater sciatic notch and descend between the ischial tuberosity and greater trochanter 2--gives branches to hamstring muscles (biceps femoris long head, semitendinosus, semimembranosis) (except short head of biceps femoris—peroneal) 64 3--branches into common peroneal n. and tibial n. (at middle of thigh) and also produces lateral sural cutaneous nerve to skin on posterolateral side of lower leg 4—common peroneal n—p. 582 --superficial branch—arises deep at level of neck of fibula and descends in lateral compartment of the leg, innervates peroneus longus m and peroneus brevis m -emerges b/t peroneus longus and peroneus brevis near ankle to supply dorsum of the foot --deep branch—arises with superficial branch -descends on interosseus membrane b/t the extensor digitorum longus m and the tibialis anterior m, innervates the muscles of the anterior compartment of the lower leg -divides into lateral branch to ext. dig. Brevis and medial branch that arises superficially b/t 1 and 2 metatarsals to supply skin of 1,2 toes 5—tibial nerve—p. 582 --enters posterior compartment and follows posterior tibial a. --branches -articular—to knee joint and ankle -muscular—muscles of post. compartment -medial sural cutaneous—crease of the head of gastroc m. -medial calcaneal—heel --terminates at ankle by dividing into lateral (1 ½ toes) and medial (other 3 toes) plantar nerves 11/29/99 JOINTS— A. Knee—hinge type synovial joint allowing flexion and extension with minor rotation 1. covered by a thin fibrous capsule and is incomplete anteriorly --attahed to the femoral condyles and the intercondylar notch 2. synovial membrane lines fibrous capsule—does not contain the cruciate ligaments 3. stability of joint due to strength of the ligaments—p. 624-625 --cruciate ligament—lies within the intercondylar notch --anterior cruciate ligament—runs from anterior margin of intercondylar notch backward to the medial surface of the lateral femoral condyle—taut when knee is extended --posterior cruciate ligament—crosses over the anterior ligament, from posterior margin of intercondylar notch to the medial femoral condyle—taut when knee is flexed --lateral and medial menisci --c-shaped fibrocartilage that aids in forming tight joint—avascular (nutrients from diffusion osmosislonger to heal)—remove if injured 65 --transverse ligament—binds ends of lateral and medial menisci --tibial collateral ligament— --broad ligament from medial femoral epicondyle to medial tibia --firmly attached to the medial meniscus --prevents medial displacement of the joint --fibular collateral ligament— --lies away from the capsule from lateral femoral epicondyle to the head of the fibula—separated out from joint --patellar ligament—continuation of the quadriceps femoris tendon from apex of patella to the tibial tuberosity 4. Bursa—p. 633 --suprapatellar bursa—under quadriceps femoris tendon, joins with joint cavity --prepatellar bursa—over surface of patella --infrapatellar bursa—subq and deep 5. blood supply—p. 626—genicular branches of popliteal a. 6. nerve supply—branches from sciatic, femoral, and obturator n.’s B. Shoulder—p. 789—glenohumoral joint 1. ball and socket synovial joint (synovial membrane / synovial fluid) 2. surrounded by loose fitting capsule strengthened by 3 anterior thickenings— superior, middle, and inferior glenohumoral ligaments --contains openings where synovial cavity connects w/ subscapular (anterior scapula) bursa and for passage of biceps brachii tendon 3. stability of joint mostly due to muscles (which lack inferiorly—therefore common site of dislocation) 4. depth of glenoid cavity increased by rim of fibrocartilage (glenoid labrum—p. 791) 5. rotator cuff— --presses humerus head into glenoid cavity --formed by tendons of subscapularis, supraspinatus, infraspinatus, and teres minor m’s. 6. bursa— --subacromial—between acromion process and the coracoacromial ligament ligament superiorly. Inferiorly—supraspinatus m. --subdeltoid—between deltoid m. superiorly and tendon of supraspinatus m. inferiorly --subscapular bursa—between tendon of subscapularis m. and neck of scapula 66 7. ligaments—p. 791 --glenohumeral—anterior thickening of joint capsule (fibrous tissue) --transverse humeral—extends between lesser and greater tubercles of humerus and holds tendon of long head biceps in intertubercular groove --coracohumeral ligament—extends from coracoid process to greater tubercle --coracoacromial—extends from coracoid process to acromion process 8. blood supply—branches of suprascapular artery and anterior and posterior humoral circumflex a’s 9. nerve supply—many small branches from axillary, suprascapular, and lateral pectoral nerve. 12/1/99 EYE Out to insclera (white)choroidretina (nervous tissue)—rods (B&W; better at detail) and cones (color; need more light)—these trap the vision --anterior chamber—watery aqueous humor (can reform)—pressure and shape of the lens --posterior chamber—jelly like vitreus humor (formed during embryonic development— does not reform --lens—change shape based on whet looking atciliar muscles—extension of choroid A. anatomy—chung—p. 313 B. innervation 1. optic nerve—begins at retina (rods and cones) and travels to cerebrum 2. CN III occulomotor—levetor palpebrae superioris m., medial and inferior rectus muscles 3. CN IV trochlear—superior oblique m 4. CN VI abducens—lateral rectus m 5. opthalmic nerve—V1 branch of N V --lacrimal nerve—lacrimal gland; superior eyelid; conjunctiva --frontal nerve—sensory to forehead and superior eyelid --nasociliary nerve—sensory nerve to eye, branches to the nasal cavity, skin over nose, lacrimal sac, sphenoid and ethmoid sinuses, ciliary body and iris 67 12/3/99 C. Blood Vessels—p. 913 1. opthalmic artery—branch of internal carotid a., enters orbit thru the optic canal beneath the optic nerve a. gives off many (10) branches to components of the orbit b. central artery of the retina—most important branch—End artery. Travels with optic nerve into the eyeball itself 2. veins—p. 914 a. superior opthalmic vein—receives smaller veins that correspond to the branches of opthalmic artery b. inferior opthalmic vein—drains the floor of the orbit, joins and drains the cavernous sinus v.communicates with facial vein D. Eye muscles—p. 911 1. 3 pairs a. lateral, medial rectus m.’s b. superior, inferior rectus m.’s c. superior, inferior oblique m.’s—rotation *levetor palpebrae superioris m. E. lacrimal apparatus—p. 916 1. superior lateral region of orbit a. composed of lacrimal glandeyelacrimal canaliculi (little tubes)lacrimal sacnasolacrimal ductnasal cavity F. Disorders— 1. glaucoma—increased intraocular pressure due to build-up of aqueous humor 2. cataract—clouding of the lens (proteins) 3. myopia—near sightedness 4. hypermyopia—far sightedness II. Ear A. Anatomy—p. 963 B. outer ear 1. blood from superficial temporal and posterior auricular a.a.’s 2. nerve from vagus, greater auricular, and lesser occipital n.n’s 3. external auditory meatus—contains ceruminous gland (makes cerumin—ear wax) 4. tympanic membrane C. middle ear—malleus, incus, stapes 1. stapedius muscle—smallest skeletal muscel in entire body a. innervated by facial n. 68 b. prevents excessive vibration from loud noises 2. tensor tympani muscle a. tightens tympanic membrane b. I: mandibular branch of trigeminal nerve (V3) D. inner ear—contains the organs for hearing and equilibrium 1. cochlea a. contains the centers for hearing—I: vestibulocochlear n. 2. semicircular canals— a. three—contain ampulla which controls dynamic (spinning) equilibrium 3. vestibule a. connects the cochlea and semicircular canals b. contains the utricle and saccule which are centers for static equilibrium (one verticle plain)